NEWBURY LOCAL
SCHOOL DISTRICT
14775 Auburn Road ท Newbury, OH 44065-9745 Application for Certified Position
Date of Application ____________
Personal Data
Name (last, first, middle) Soc.
Sec. #
Present Address Phone
No.
Permanent Address Phone
No.
Are you a U.S. Citizen? Yes c No c If not, do you intend to become
a citizen? Yes c
No c
Have you ever been convicted
of or pleaded guilty to any felony, any violation of
R.C. 2907.04 or 2907.06, or
division (A) or (C) of R.C. 2907.07, any offense of violence,
theft offense (as defined in
R.C. 2913.01), drug abuse offense (as defined in R.C. 2925.01)
which is not a minor misdemeanor, or
any misdemeanor sex offense? Yes
c No c
Do you have the ability to
perform all of the essential functions of this
position with or without a reasonable
accommodation? Yes
c No c
Position(s) applying for:
Referred by:
Names of friends or relatives employed
by this district:
Are you presently under contract to
another district? Yes c
No c
If yes, when does contract expire?
CERTIFICATION
Area(s) Type
of Certificate Expiration
Date
1.
2.
3.
4.
5.
_____________________________________________________________________________________________________________________
Academic and Professional Training
High School(s), College(s),
Universities attended (include location).
List highest degree first.
School and Location Degree Year Major Minor
1.
2.
3.
4.
5.
Experience in Education
Please furnish all required
information on this form- do not refer to other sources. List all educational experience (teaching,
sub, student teaching) in reverse chronological order.
School and Location Position Date(s)
1.
2.
3.
4.
5.
Other work experience and
achievements valuable to your career:
Extracurricular activities
you would be willing to supervise if employed:
ญญญญญญญญญญ
Recognition (Honors,
Awards, etc.)
Professional Organizations
and Activities
Summarize Your
Experience/Strengths in Education
Professional References
Please list below the names
and addresses of three (3) persons who can speak
of
your professional competency and character.
Name _________________________________________ Type of Acquaintance ___________________________________
Address _______________________________________________________________________________________________
Home Phone ( ) _________________________ Office Phone ( ) ____________________________________
Name ________________________________________ Type of Acquaintance ___________________________________
Address ________________________________________________________________________________________________
Home Phone ( ) ________________________ Office Phone ( ) _______________________________________
Name _________________________________________ Type of Acquaintance ____________________________________
Address ________________________________________________________________________________________________
Home Phone ( ) ___________________________ Office Phone ( ) ________________________________________
Do we have permission to contact the above-named persons? Yes _________ No _____________
References
Please list below the names
of three (3) persons not related to you
whom
you have known at least one year.
Name
_______________________________________ Type
of Acquaintance _______________________
Address
______________________________________________________________________________________
Home Phone ( ) _________________________ Office Phone ( ) __________________________________
Name
_______________________________________ Type
of Acquaintance _______________________
Address
______________________________________________________________________________________
Home Phone ( ) ____________________________ Office Phone ( ) ___________________________
Name
_______________________________________ Type
of Acquaintance _______________________
Address
______________________________________________________________________________________
Home Phone ( ) _____________________________ Office Phone ( ) ___________________________
Name
_______________________________________ Type
of Acquaintance _______________________
Address
______________________________________________________________________________________
Home Phone ( ) ______________________________ Office Phone ( ) ___________________________
Do we have permission to
contact the above-named persons? Yes ________ No
_________
I hereby certify that
answers on this application are true and correct to the best of my knowledge
and belief, and that any deliberate misrepresentation of fact contained herein
may be grounds for invalidating my contract commitments resulting from this
application. I understand that my
employment will be subject to the laws of the State of Ohio and to the job
descriptions and policies adopted by the Newbury Local Board of Education.
______________________________________________________ ____________________________________
Signature Date
NOTE: Unless reactivated by written request, this
application will be destroyed two (2) years from date of filing.
The Newbury Local School
District Board of Education does not discriminate on the basis of race, color,
national origin, sex, religion, age, or disability in employment, or the
provision of services.