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Teacher Application

by Kris Van Pelt

October 10, 2005

401.4-Exhibit A

BOARD OF DIRECTORS

OGDEN COMMUNITY SCHOOL DISTRICT

TEACHER APPLICATION FORM

 1.        Please complete all information and forward to:

                      Superintendent

                      Ogden Community School District

                      P.O. Box 250

                     Ogden, Iowa 50212

 

 2.        Personal letter of application.

 3.        Resume

 4.       Credentials will be forwarded to above address from__________College or University.

5.        Transcripts

6.        Copy of Teaching Certification

PERSONAL INFORMATION:

Last Name______________________ First____________________ Middle_________

Business Address_____________________________________ Telephone___________

City ___________________State _________________________Zip________________

Home Address _______________________________________Telephone___________

City___________________ State _________________________Zip_________________

Present Position__________________________________________________________

Are you under contract at the present time?_____________________________________

Types of certification/licenses or authorizations held ______________________

License/authorization No. ____________________________________________

Are you trained in first aid techniques? __________Yes No

Training__________________________________________________________________

Are you trained in CPR training? ________________Yes No

Training __________________________________________________________________

Were you honorably discharged from the United States military forces after service between

the periods of December 7, 1941 and December 31, 1946, or June 25, 1950 to January 31,

1955, or August 5, 1964 to May 7, 1975, or during the Persian Gulf conflict?

_____________Yes _______________No

Please complete if you are claiming a veteran's preference:

Active Duty/Reserve Duty

Branch________________________ Period of Duty____________________

Location of Duty______________ _Rank at Discharge________________

Has there ever been a judicial or administrative finding that you have abused or mistreated a

minor or child? (If yes, attach explanation.) _____________Yes ______________No

401.4 Page 2

EMPLOYMENT HISTORY

List all experience in chronological order.

NAME         LOCATION     POSITION       FROM/TO         SUPERVISOR             PHONE

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

PROFESSIONAL PREPARATION

INSTITUTION                  LOCATION                  MAJOR/MINOR                    DEGREE

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

REFERENCE (LIST AT LEAST TWO)

NAME                      POSITION                          RES. PHONE                   BUS. PHONE

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

I certify that the information given in this application (and accompanying resume, if any,) is true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application, and I authorize Ogden Community School District to contact my references and prior employers, and release from all liability or responsibility all persons or corporations requesting or supplying information. I understand that giving false, incomplete, or misleading information in my application or inter-view may result in withdrawal of my application for consideration or in discharge.

I understand that the Ogden Community School District will do a criminal records and child abuse check on me.

If my duties will include driving a school vehicle for which I need a CDL license and if the vehicle transports 16 or more persons or the vehicle weights 26,001 pounds or more, I have been informed of the requirement to submit to a drug test prior to being employed by the District to perform a safety-sensitive function. I consent to submit to the District's drug and alcohol testing program. I also understand that if I have a positive drug test, I will not be considered further for employment by the District.

I UNDERSTAND THAT I MAY NOT BE EMPLOYED UNTIL APPROVAL IS GIVEN BY THE DISTRICT'S BOARD OF DIRECTORS.

Signed_________________________________________________Date_________________

The Ogden Community School District provides equal employment opportunities to all persons regardless of race, color, national origin, creed, religion, marital status, parental status, age or disability. Questions regarding compliance with equal employment opportunities should be directed to the Superintendent at Box 250, Ogden, Iowa 50121, telephone number (515) 275-2894.

Teacher Application

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