KESHEQUA CENTRAL SCHOOL DISTRICT
15 Mill Street, P.O. Box 517
Nunda, New York 14517
Ph: 585-468-2541 Fax: 585-468-3814
PROFESSIONAL STAFF APPLICATION
POSITION PREFERENCE
Elementary Middle School High School Other
(Guidance,
Full-Time Part-Time Psychology,
Administrator)
Please specify preferences: Grade Level
Subject Areas
PERSONAL INFORMATION
Name
Last First M.I.
Other Name(s)
Please provide any additional information regarding
names you have used, which may be
necessary to enable a check of your work or school records.
Present Mailing Address Phone
Permanent Mailing Address Phone
Social Security # N.Y.S. Teachers’ Retirement#
NEW YORK STATE CERTIFICATION
N.Y.S. Certification: Yes No Pending If yes or pen
ding please complete:
Area Subject
Initial Professional Transitional Provisional Permanent
Effective Date Expiration Date Certificate #
Area Subject
Initial Professional Transitional Provisional Permanent
Effective Date Expiration Date Certificate #
New York State Coaching Certificate Yes No Pending
The Keshequa Central School District does not discr
iminate because of race, color, creed,
religion, national origin, political affiliation, s
ex, sexual orientation, age, marital
status, military status, veteran status, or disabil
ity.
Please attach a copy of all certificates
Revised 4 – 04
EDUCATION AND PROFESSIONAL TRAINING
School Attended
Location
Dates
Degree
Major
Minors
High School
Undergraduate
Graduate
Total Number of
Graduate Hours
beyond last degree
TEACHING EXPERIENCE
List most recent experience first. Include any subs
titute teaching and indicate as such.
Administrative applicants: please include both administrative and teaching experience.
Inclusive Dates:
Name and Location of
School
Specific Nature of
Position: i.e., grade
level, subject, etc.
Total
Years
If full-
time
position,
annual
salary
Did you
receive
tenure?
From To
1.
2.
3.
4.
Reason for Leaving (Refer to numbers above) Reason
for Leaving (Refer to numbers above)
1.
2.
3.
4.
EDUCATIONAL EXPERIENCE
If fewer than 3 years of regular full-time employme
nt, include student teaching experience here.
Inclusive Dates:
From To
Name and Location of School
Subject or Grade Level
1.
2.
RELATED PROFESSIONAL EXPERIENCE
Educational travel, lectures, addresses, publicatio
ns, organizational memberships, committee chairs
or memberships, participation in educational experiences, innovations, special programs, elective
positions held. This section should include your experience with computers and technology as
organizational tools (i.e., word processing, spreadsheets, database) to instructional delivery
(i.e., Internet, CD Rom multimedia, distance learning).
Revised 4 – 04
MILITARY SERVICE AND WORK EXPERIENCE OTHER THAN TEA
CHING
List here in chronological order all practical expe
rience other than teaching, including trade or
business experience, military service, social work, work in summer camps, involvement with youth
activities, etc.
Inclusive Dates
Kind of Work
From
To
Name and Address of Employer
Name and Address of Supervisor who
would know most about this work.
List below any extracurricular or athletic activities you can direct.
Estimate your attendance at work or school for the
last three years (days, weeks, months)
Excellent Very Good Good Fair Poor
Have you ever been dismissed or asked to resign? Have you ever agreed to resign or agreed
to accept a disciplinary penalty in settlement of disciplinary charges? Have you ever
resigned to avoid a denial of tenure or dismissal during a probationary period? If yes to
any or all of the above, please explain:
Are you a party to any agreement with a prior employer limiting the right of your prior
employer to respond to reference checks by prospective employers? If yes, please explain
Except for minor traffic violations, have you ever been convicted of a crime?
If yes, please give details
REFERENCES
Give names of those who have closely observed your
work as a teacher or as a student. In
the case of experienced teachers or supervisors, present and former superintendents,
principals and other supervisors are preferred. Beginning teachers will please include
practice teaching supervisors. If references may not be contacted before a certain date,
please indicate the date by the name of the reference.
Office Use
Name Official
Position
Present Address/Zip/Phone Sent Rec’d
Revised 4 – 04
In your own handwriting state why you feel you are
well qualified for employment with the
Keshequa Central School District and any additional professional information that you
think might be of value in our considering you for a position.
Thank you for completing this application and for
your interest in Keshequa Central School.
Please return application to:
Superintendent
Keshequa Central School
P.O. Box 517
Nunda, New York 14517
I hereby certify that the statements made in this application are true to the best of my
knowledge and belief. I hereby authorize any individual, company, or institution with
whom I have been associated to furnish the Keshequa Central School District with any
information concerning my employment.
Date Signature of Applicant
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