Sullivan County Department of Education Application for Professional Employment Applicant Name Form 4170.01 Notice: No reimbursement of expenses for Certification(s) applicant will be granted Dept. IV Return to: FOR OFFICE USE ONLY Director of Schools Date Received___________ Sullivan County Department of Education PO Box 306 Blountville, TN 37617 Dear Applicant: Before your application can be considered for filling a vacancy, the following additional items must be received for placement in your file: a. Placement papers or credentials from the institution from which you graduated. Date received in Director’s Office____________________________________ b. Transcript of your course work Date received in Director’s Office____________________________________ c. Verification of a valid Tennessee certificate in the area(s) seeking employment. Date received in Director’s Office____________________________________ d. Resume or other information of your history of teaching experience (optional). Date received in Director’s Office____________________________________ e. Praxis test scores (effective 7-1-82). Date received in Director’s Office____________________________________ f. References from persons who have knowledge of your teaching. (Our office will send for these from the list found on the application). Please note that items a,b,c,d, and e are the responsibility of the applicant. This application will be placed on file for one year for consideration when vacancies arise. It must be renewed and kept up-to-date if it is to remain in our active file. It should be complete and accurate in every detail. The Sullivan County Department of Education is an equal opportunity employer. No discrimination will be made on the basis of sex, marital status, race, creed, color, religion, national origin, age or disability. (All questions must be answered, if not applicable, please make the notation N/A) Telephone (Cellular) Telephone (Home) 1. Name Email Last First Middle/Maiden 2. Address Zip 3. Date of Application Social Security No. 4. Present Employment Starting Date 5. Position applied for 6. Areas of certification 7. Type of Tennessee Teaching Certificate Held Tennessee Teaching Certificate Number 8. Student Teaching: Where 9. Name of supervising teacher EDUCATION Institution & Complete Address Degree Date Major Sem. Minor Sem. Graduated Hrs. Hrs PROFESSIONAL EXPERIENCE Name of School & Complete Grades/Subject Taught Dates of No. Yrs. Reason for Leaving Address Employment Employed 10. Military Service______________________ Length of Service__________________________ 11. Are you able to perform the essential functions of the job either with or without a reasonable accomodation? ___Yes ____ Select: 12. Underscore any of the following which you are able to direct or coach successfully; Debates, School Plays, Oratorical Contests, Orchestra, Clubs, Football, Basketball, Track, Tennis, Baseball, Golf, Swimming, Soccer, Playground Activities. 13. References: Give at least five references, including especially the director and principals under whom you have worked and others who have knowledge of your teaching competence. Name Complete Address Official Position Include Zip Code You may add by letter or resume any additional information which will give us a more complete estimate of your qualifications. Testimonials may also be included. Why do you want to leave your present job? May inquiry be made of your present employer and former school records regarding your character, qualifications, and record of employment? Give your name exactly as it appears on school records: Note: Application Not Complete Unless Information Below is Filled Out. CERTIFICATION OF ACCURACY (as required by Board Policy and TCA 49-131B) I certify that all of the statements made in this application are true, complete, and correct, to the best of my knowledge and belief and are made in good faith; I understand that false information may be grounds for rejection of my application. I recognize that, if I am employed, the Sullivan County Department of Education will assign or reassign me to a specific position as the need arises. I hereby certify that I have not been convicted of a misdemeanor or a felony in any state of the United States. I further certify that I have not been dismissed from any previous employment for improper or unprofessional conduct, ineffective services, neglect of duty, incompetence, or insubordination as the same are defined in Section 49-1401 of the Tennessee Code. If my most recent employer were another Tennessee public school system and if my termination was voluntary, I hereby certify that my resignation was, or will be submitted at least 30 days prior to the beginning date stated hereon; or if within 30 days, that the previous board has waived its rights to such notice. A copy of my letter of resignation or of the said board action is attached or will be provided. I understand that misrepresentation of any of these certifications may subject me to the penalties prescribed in Sections 49-1317 or 49-1318 of the Tennessee Code. Signature Date If you cannot sign the above, please give a full explanation: Revised 5/02 DIV1-a SUPERVISOR OF HUMAN RESOURCES SULLIVAN COUNTY SCHOOLS (423) 279-2231 PO BOX 306 OBI NO: TN9309402 BLOUNTVILLE, TN 37617 READ CAREFULLY BEFORE COMPLETING I certify that all information provided in my application is complete and correct to the best of my knowledge. I agree that if any information or answers to questions change either before or after employment, I will notify the Human Resources Office in writing immediately. I authorize the Director of Schools or his designee to complete confidential reference and background checks including history searches and finger print verifications pursuant to TCA 49-5-513 (a). I understand that all employees are subject to assignment of duties by the Director of Schools and/or principal according to law. I hereby certify that I have not been convicted of a misdemeanor or a felony in any state of the United States. I further certify that I have not been dismissed from any previous employment for improper or unprofessional conduct, insubordination as the same are defined in TCA 49-2-203. If my most recent employment were another Tennessee public school system and if my termination were voluntary, I hereby certify that my resignation was, or will be submitted at least 30 days prior to the beginning date stated hereon, or, if within 30 days prior to, the previous board has waived its rights such notice. A copy of my letter of resignation or of the said board action is attached or will be provided. I understand that misrepresentation of any of these conditions shall be sufficient grounds for termination of employment, disqualification of the application, and shall also constitute a Class A misdemeanor which must be reported to the district attorney general. Signature: Date: CONSENT FOR CRIMINAL RECORDS CHECK BY LAW ENFORCEMENT AGENCIES The Sullivan County School System requires a TBI/FBI criminal background check on all new employees. An acceptable fingerprint record is a part of the criminal background check. The cost of the investigation is $48.00, which will be deducted from your first three checks. This section to be completed by the applicant I Social Security Number PLEASE PRINT have applied for a position with the Sullivan County School System, and I consent to a criminal background check by la enforcement agencies under the conditions stated above. I also authorize the release of such information to the Sullivan County Board of Education now and at any time during my employment, and hereby release, discharge and waive any and all claims which may arise against Sullivan County Schools for the release of accurate information. Street:___________________________________________________ CURRENT ADDRESS: City, State, Zip____________________________________________ Driver’s License #___________________________DOB___________ APPLICANT’S SIGNATURE: DATE ---------------------------------------------FOR OFFICE USE ONLY-------------------------------------------------- TBI CHECK: DATE BY Signature ___________The TBI check shows no history of a criminal record for this applicant ___________The TBI check shows a history of a criminal record for this applicant. A report is attached. FBI CHECK: DATE BY Signature __________The FBI check shows no history of a criminal record for this applicant. __________The FBI check shows a history of a criminal record for this applicant. A report is attached.