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.
