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					                       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.

				
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