certified application

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                             MURCHISON INDEPENDENT SCHOOL DISTRICT
                               Employment Application for Professional Personnel
 We consider applicants for all positions without regard to race, color, national origin, age, religion, sex, marital or
veteran status, the presence of a medical condition or handicap that is not job related, or any other legally protected
                                                        status.
                                          An Equal Opportunity Employer

                      Date of Application ______-______-______      Social Security No. _______-_______-_______
Personal Data




                      Name _________________________________________________________________________
                               Last                          First               Middle

                      Current Address _________________________________________________________________
                                      _________________________________________________________________
                                      _________________________________________________________________

                      Home Phone (_______) _______-_______       Work Phone (_______) _______-_______


                      Position for which you are applying _________________________________________________
Position Data




                      Type of Employment: Full Time ____ Part Time ____ Summer Only ____

                      Date Available ____-____-____

                      Former ___________________________ISD Employee:          yes____ No____

                      If yes, give dates of employment: From ____-____-____ To ____-____-____


                      Check highest level attained.
Education /Training




                      __ Not high school graduate (Circle last grade completed) 1 2 3 4 5 6 7 8 9 10 11 12

                      __ High school graduate      __ GED               __ Less than two years in college
                      __ Two or more years college __ Bachelor’s degree __ Master’s degree

                      __ Other training or education_______________________________________________

                                                _______________________________________________
                      Licenses/certifications held
                                                _______________________________________________
                Schools Attended: List all applicable information:
             Name of School &      Course of Study                 Diploma / Degree      Year Graduated
                Location          Major/Minor Fields                Or Certificate        College Only
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                                  Name of           Supervisor’s
                                                                         Position/Title      Mailing Address   Phone No.
                                  Employer             Name
  Teaching Experience




                                  Employer              Name            Position/Title      Mailing Address    Phone No.
     Employment Experience




                             Type of certificate held at present:

                             __   None
                             __   Valid Texas
                             __   Valid other state ______________
                             __   Emergency (Texas)
                             __   Texas one-year certificate: Expiration date:        ______-______-______
                             __   Texas temporary administrative: Expiration date:    ______-______-______
     Certification




                             Areas of Specialization:

                             __   Administrator                      __ All level art       __ Vocational
                             __   Superintendent                     __ All level health/PE __ Nurse
                             __   Principal                          __ All level music     __ Visiting teacher
                             __   Mid-management administrator       __ Librarian           __ Supervisor
                             __   Elementary                          __ Counselor          __ Other (specify):
                             __   Elementary & Kindergarten           __ Special Ed.
                             __   Secondary (Junior and Senior High) ___________________ _______________________
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                        Omit references to organizations that would reveal race, age, ethnic origin, or religious persuasion.

                           Publications/articles___________________________________________________________
  Professional Data




                           Seminars/workshops conducted ________________________________________________

                           Other related professional activities
                            ____________________________________________________________________________
                            ____________________________________________________________________________
                            ____________________________________________________________________________




                           Are you aware of any reasons you would not be able to perform the duties to the position for
                            which you are applying? __ yes __ No If yes, please explain
  General Information




                            ____________________________________________________________________________
                            ____________________________________________________________________________
                            ____________________________________________________________________________

                           Do you have a relative who is a member of the Murchison ISD Board of Education?

                            If yes, please give the name of relative and relationship: ______________________________
                                                                                       ______________________________




                        Please make a statement concerning your reasons for desiring a position with the Murchison
                        Independent School District. (Please use back of this sheet if necessary.)
  Personal Statement
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                 I affirm that all information provided in this application is true and accurate to the best of my
                 knowledge, and understand that any deliberate falsifications, misrepresentations, or omissions of
                 facts may be ground for refection of my application or dismissal from subsequent employment.

                 I authorize the references listed above to give you any and all information concerning my previous
                 employment and any pertinent information they may have, personal or otherwise, and release all
                 parties from all liability for any damage that may result from furnishing same to you.
  Verification




                 I understand that the district is required by Texas Education Code 21.917 to obtain criminal history
                 record information on applicants for employment.

                 This application becomes the property of the district. The district reserves the right to accept or
                 reflect it. This application shall be considered active for a period of time not to exceed 365 days.
                 Any applicant wishing to be considered for employment beyond this time period may inquire as to
                 whether or not applications are being accepted at that time.

                 ____________________________________________________-
                 Signature of Applicant