Resign Certification of Employment - PDF

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					                                                                              CERTIFIED EMPLOYEE APPLICATION
                                                   DATE ________________________________

 Thank you for expressing an interest in the Cherokee County Schools. This application should be fully completed in
 your own handwriting and signed. Accuracy and completeness are factors in the consideration of your application. This
 application will remain active for one year from the date received.
 PERSONAL INFORMATION
 Last                                       First                                      Middle
 Name:                                      Name:                                      Name:                                      SS #:
 Street                                                                                                                                          Zip
 Address:                                                 City:                                    State:                                        Code:
 E-Mail
 Address:                                                                   Telephone:

 POSITION INFORMATION
 Applicants must be certified or eligible for certification in area(s) of choice.

 I am applying for:                 Teacher                          Administrator                 Speech Language Pathologist
 (Check all that apply)             Counselor                        Media Specialist              Other____________________________

     Full-time only                                                   Part-time/Job Share only                                        Either Full or Part-time
 Date available for employment:_________________________________________________
 Other than English, specify any language(s) in which you are proficient:
 _______________________________________
 How did you become aware of the Cherokee County School District? (please specify details)
   Job Fair _________________________       Internet ________________________           Personal referral
   Advertisement_____________________       Other __________________________            Cherokee County Resident

 CERTIFICATION

The State of Georgia requires that all teachers, principals and other professional personnel hold a valid Georgia Educator’s
Certificate. Check all that apply to your status.
 Enclose a copy of Educator Certificate(s)/License(s). Application is not complete without a copy.

     I hold a Georgia Certificate ..................................................     Current     Expired

     I hold an Educator Certificate/License in another state ....... Current Expired
     State(s):____________________________Field(s):___________________________________(Copy required)

     I do not hold a valid Georgia Certificate but will have met all qualifications by ___/___/___
     in the field(s) of _____________________________________________


 Georgia requires passing scores on appropriate educator tests for full Certification. Complete the following educator
 testing information. Enclose a copy of all score reports.
                                                                                                                                    ENTERED_____________



                                                                                                                                                                          R1___R2___R3___R4___




     I have passed all Georgia required certification tests.
                                                                                                                                                                                                 PERSONNEL USE ONLY
                                                                                                            BY_________________

                                                                                                                                       DATE__________



                                                                                                                                                           CERT___CI___




     I have taken all required Georgia certification tests but have not received scores.
                                                                                                                                         INTERVIEW




         Test date: _______________

     I have passed required educator tests to obtain certification in another state.
         State(s): ____________________________

     I have not passed all required certification tests.


                                                                                                                                                                                                                      1
 EDUCATIONAL AND PROFESSIONAL TRAINING
 Beginning with the most recent, list schools attended, including postgraduate, graduate, university/college,
 business school, or others.
   Institution and Location         From/To       Course of Study          Diploma / Degree          Completion Date




                        INTERNSHIPS / STUDENT TEACHING EXPERIENCE
    School / School System             State       Grade(s) /Subject           Supervising Teacher              Date




 REFERENCES
 List below the four individuals you have requested to complete a CCSD Confidential Reference Form. These
 people should be the most qualified to answer questions concerning your qualifications. Your current or most recent
 principal/supervisor must be included. If you are a beginning teacher, a college placement file may be used.
                        Name                                        Position                   Area Code / Phone #




 PERSONAL DATA
 NAME, ADDRESS, and TELEPHONE NUMBER OF A PERSON WHO WILL ALWAYS KNOW HOW TO CONTACT YOU:

___________________________________________________________________________________________
                Name                                                                   Telephone Number
___________________________________________________________________________________________
             Street Address                                         City                     State         Zip Code


  Yes*     No Are you currently under contract with another school system/district? (If yes, until _____________)
  Yes*     No Have you ever received a reprimand, failed to have your contract renewed, or been asked to resign?
  Yes*     No Have you ever had a teaching certificate or credential denied, revoked, or suspended in any state?
  Yes*     No Have you received an unsatisfactory evaluation during the last five years of employment?
  Yes*     No Have you ever been charged, convicted, or pled nolo contendere to a crime other than minor traffic
              violations? Please note: Driving While Intoxicated (DWI), Driving Under the Influence (DUI), and similar
                charges are NOT considered minor traffic offenses and must be reported.
  Yes*     No Have you ever been investigated by the Educator Licensing Agency of any state?
  Yes*     No Have you ever been the subject of a school district or police investigation?
  Yes*     No Have you ever pled guilty to or been convicted of any offense relating to the possession or
              distribution of illegal drugs
  Yes*     No Do you have relatives working for the Cherokee County School District?
  Yes*     No Is there any reason you will not be able to work each day without absences except for routine
              illness?
  Yes*     No Are you subject to any visa or immigration status which would prevent lawful employment at this
              time or in the future? If you are not a citizen of the United States of America, you must furnish a copy of
              your Permanent Residency Permit or other documentation allowing you to legally work in this country.


 * If you answered YES to any question, you must attach a complete and thorough explanation on separate
 paper.
                                                                                                                            2
WORK HISTORY
 Account for all years since High School. Include years not employed. Begin with current or most recent assignment.
 DO NOT SUBMIT A RESUME IN LIEU OF COMPLETING THE WORK HISTORY. YOU MAY ATTACH ADDITIONAL PAGE(S) IF REQUIRED.

                                           TEACHING EXPERIENCE
 School District and    Grade /     Supervisor’s       Phone         Years       Dates of Employment           Reason
   School Name          Subject       Name             Number        Worked         From       To            for Leaving




                                        NON-TEACHING EXPERIENCE
                                    Supervisor’s       Phone         Years       Dates of Employment           Reason
           Employer                   Name             Number        Worked         From       To            for Leaving




                                            MILITARY EXPERIENCE*
                                      From              To            Number       Highest
       Branch of Service           Month / Year     Month / Year     of Months      Rank            Type of Discharge



 *NOTE: IN ORDER TO VERIFY MILITARY EXPERIENCE THE APPLICANT/EMPLOYEE IS RESPONSIBLE FOR PROVIDING A COMPLETED DD 214 FORM.


List professional recognitions, honors received, community activities, and any extracurricular activities or coaching for
which you have special preparation, experience, or interest:




STATEMENT
 Explain briefly why you chose the education profession and why you desire employment in the Cherokee County School
 District:




                                                                                                                              3
PHILOSOPHY OF EDUCATION




PERSONAL AFFIRMATION

I verify that all information that I have provided on this application is true and complete to the best of my knowledge. I
am aware that providing false or misleading information or the withholding of facts, including facts of one’s criminal
record, on this application will be grounds for refusal to hire me, and that if employed, grounds for termination of
employment. If employed, I agree to abide by the policies, rules and regulations of the Cherokee County School District
and State Board of Education.

My signature further authorizes the Cherokee County School District to investigate my past employment activities,
personal references and criminal record (as provided by OCGA 20-2-211), to determine my suitability for the position
for which I am applying, and authorizes representatives of the Cherokee County School District to contact my
references, previous employers, schools attended, court officials, law enforcement authorities, and other individuals. I
understand that the Cherokee County School District may investigate other sources or references other than those
given in this application. I agree to pay the cost of $25.00 for fingerprinting by the appropriate law enforcement officials
and I further agree to sign appropriate forms giving consent to a criminal record check through the National Crime
Information Center and the Georgia Crime Information Center.

I understand that nothing in this employment application, in the statements or policies of the Cherokee County School
District or Cherokee County Board of Education, or in my communications with any District or Board official is intended
to create an employment contract. No promises of employment have been made to me. I also agree, if employed, to
attend orientation sessions as requested.

I understand that upon employment I will be issued a temporary contract pending the outcome of my criminal record
check.

DATE _________________________ SIGNATURE OF APPLICANT_______________________________________


Your application will be kept on file for one year.



                                                           Return Application To:

                                            CHEROKEE COUNTY SCHOOL DISTRICT
                                                    Personnel Department
                                                        P.O. Box 769
                                                    Canton, Georgia 30169
                                                 Telephone: (770) 479-1871
                                                personnel@cherokee.k12.ga.us

                    The Cherokee County School District is an equal opportunity employer and does not discriminate in employment
                                  on the basis of race, color, sex, religion, creed, national origin, age or disability.




                                                                                                                                   4
                         Cherokee County School District
                         111 Academy Street P.O. Box 769
                              Canton, Georgia 30169


       RELEASE AUTHORIZATION – Consent to Criminal History Record Inquiry

I hereby authorize the Cherokee County School Police Department or the Cherokee
County School Personnel Department to receive any criminal or driver’s history
information pertaining to me, which may be in the files of any local, state, or federal
agency.

I also request and authorize a review and full disclosure of all records concerning me
to any authorized agent of the Cherokee County School Police Department, whether
the records are public, private or confidential.

The intent of this authorization is to give my consent for full and complete disclosure of
the records of educational institutions; internal investigations and disciplinary records;
and employment and pre-employment records. I understand that any information
obtained by a personal history background investigation, which is developed directly
or indirectly, whole or in part, will be considered in determining the suitability for
employment by the Cherokee County School District.

A photocopy or facsimile of this release authorization will be as valid as the original,
even though the photocopy does not contain my original signature.

I hereby release any and all individuals, organizations, previous employers, reporting
agencies, and others stated above, from any liability or damage, which may result
from providing the requested information.


______________________________                             _____________________
Signature of Applicant                                     Date

This consent expires 18 months from the date above. After this period, no criminal history
record inquiry shall be obtained from GCIC without submission of a new current consent form.



I further authorize the Cherokee County School Police Department to periodically run
additional criminal history record inquiries without seeking additional consent.


______________________________                             _____________________
     Signature of Applicant                                     Date



CSPD 41/42                                                               Revised 9/5/2006
                            Cherokee County School District
                       Criminal History Record Inquiry
Date ______/______/______                      PLEASE PRINT                   COMPLETE ALL INFORMATION



___________________________, ______________________ _____________________
LAST NAME                            FIRST NAME                              MIDDLE NAME

Position(s) Applied For _______________________________________________________

NAMES YOU HAVE EVER USED - List all nicknames, maiden names, previous marriages,
and/or aliases, etc.
_________________________________________________________________________
_________________________________________________________________________

DATE OF BIRTH _____/_____/_____             SOCIAL SECURITY # _________-______-__________

Sex ____ Race _____ Height ______ Weight _______ Eye Color ______ Hair Color ______

Current Address        __________________________________________________________
                       __________________________________________________________
Home Telephone         ____________________ Work/Cell Phone ______________________

Driver’s License #     _____________________ State _____ Class ___ Exp Date _________


List all states and countries where you have ever had a driver’s license:
__________________________________________________________________________
__________________________________________________________________________
List all states and countries where you have ever lived:
__________________________________________________________________________
__________________________________________________________________________

                                Police Use Only - Do not write in this box
                                                                                                       CONFIDENTIAL REFERENCE FORM

                                                                                                                 Please check all that apply:
CHEROKEE COUNTY SCHOOL DISTRICT                                                                                  CERTIFIED EDUCATOR 
PO BOX 769, CANTON, GA 30169                                                                                     CLASSIFIED POSITION 
TELEPHONE       (770) 479-1871                                                                          SUBSTITUTE TEACHING POSITION 
        FAX     (770) 720-3490
                                                                               Applicant           ______________________________
To__________________________________                                           SS#                 ______________________________
       Name of Reference (Please Print)                                                                 Complete # optional, last 4 digits required
PLEASE DO NOT RETURN THIS FORM TO APPLICANT                                    Position            ______________________________

Please supply the Cherokee County School District with the requested information. I consent to the release of all reference
information and specifically release you from all liability arising from your giving the requested information about me. I waive all rights
that I may have to examine this reference information.
                                                                             ________________________________________________
                                                                               Applicant’s Signature                                          Date

The above applicant has applied for a position with the Cherokee County School District and has listed you as a reference. This
reference form will be included in the applicant’s file for review by school administrators. The reference is confidential and will not be
shared with the applicant. Your prompt reply is appreciated.
                                               I. THIS SECTION TO BE COMPLETED FOR ALL APPLICANTS
                                                            NOT          TOP 5%       TOP 20%     MIDDLE 50%      LOW 20%        LOWEST 5%
                   PROFESSIONAL TRAITS
                                                          OBSERVED     EXCELLENT       GOOD        AVERAGE          FAIR        UNACCEPTABLE
    Ability to work with administrators/peers
    Ability to work with parents/community
    General appearance
    Adaptability, dependability, reliability
    Displays tact and self control
    Positive attitude
    Personal initiative
    Energy level
    Verbal/written communication
    Prompt, neat, accurate reporting
    Learns skills easily
    Ability to accept criticism
    Takes pride in work
    Attendance, punctuality
    Observes safety rules
    Job performance unaffected by personal issues

    II. THIS SECTION TO BE COMPLETED FOR CERTIFIED EDUCATOR APPLICANTS ONLY (TEACHING, SERVICE OR LEADERSHIP)
    Care of room
    Creativity
    Enthusiasm for teaching
    Involvement in school activities
    Knowledge of subject matter
    Leadership ability
    Maintains appropriate discipline
    Organizational skills
    Potential for success
    Teaching strategies/skills

        Is candidate open-minded and receptive to suggestions?                            YES  NO 
        Would you hire this candidate to work with or near children?                      YES  NO 
        If candidate applied to you for a job, would you employ/re-employ this person? YES  NO 
Has candidate ever failed to be recommended, asked to resign, or given a letter of reprimand/concern? YES  NO 
Do you prefer that we call you for additional information? _____       If YES, provide phone number: ______________________
General remarks or explanations: ______________________________________________________________________________

_________________________________________________________________________________________________________

__________________________________________ _________________________                               _________________________________
Signature                                                    Date                                  Title, if Applicable

Cherokee County Public Schools is an equal opportunity employer and does not discriminate in employment on the basis of race, color, sex, religion,
                                                     creed, national origin, age or disability.
                                                                                                       CONFIDENTIAL REFERENCE FORM

                                                                                                                 Please check all that apply:
CHEROKEE COUNTY SCHOOL DISTRICT                                                                                  CERTIFIED EDUCATOR 
PO BOX 769, CANTON, GA 30169                                                                                     CLASSIFIED POSITION 
TELEPHONE       (770) 479-1871                                                                          SUBSTITUTE TEACHING POSITION 
        FAX     (770) 720-3490
                                                                               Applicant           ______________________________
To__________________________________                                           SS#                 ______________________________
       Name of Reference (Please Print)                                                                 Complete # optional, last 4 digits required
PLEASE DO NOT RETURN THIS FORM TO APPLICANT                                    Position            ______________________________

Please supply the Cherokee County School District with the requested information. I consent to the release of all reference
information and specifically release you from all liability arising from your giving the requested information about me. I waive all rights
that I may have to examine this reference information.
                                                                             ________________________________________________
                                                                               Applicant’s Signature                                          Date

The above applicant has applied for a position with the Cherokee County School District and has listed you as a reference. This
reference form will be included in the applicant’s file for review by school administrators. The reference is confidential and will not be
shared with the applicant. Your prompt reply is appreciated.
                                               I. THIS SECTION TO BE COMPLETED FOR ALL APPLICANTS
                                                            NOT          TOP 5%       TOP 20%     MIDDLE 50%      LOW 20%        LOWEST 5%
                   PROFESSIONAL TRAITS
                                                          OBSERVED     EXCELLENT       GOOD        AVERAGE          FAIR        UNACCEPTABLE
    Ability to work with administrators/peers
    Ability to work with parents/community
    General appearance
    Adaptability, dependability, reliability
    Displays tact and self control
    Positive attitude
    Personal initiative
    Energy level
    Verbal/written communication
    Prompt, neat, accurate reporting
    Learns skills easily
    Ability to accept criticism
    Takes pride in work
    Attendance, punctuality
    Observes safety rules
    Job performance unaffected by personal issues

    II. THIS SECTION TO BE COMPLETED FOR CERTIFIED EDUCATOR APPLICANTS ONLY (TEACHING, SERVICE OR LEADERSHIP)
    Care of room
    Creativity
    Enthusiasm for teaching
    Involvement in school activities
    Knowledge of subject matter
    Leadership ability
    Maintains appropriate discipline
    Organizational skills
    Potential for success
    Teaching strategies/skills

        Is candidate open-minded and receptive to suggestions?                            YES  NO 
        Would you hire this candidate to work with or near children?                      YES  NO 
        If candidate applied to you for a job, would you employ/re-employ this person? YES  NO 
Has candidate ever failed to be recommended, asked to resign, or given a letter of reprimand/concern? YES  NO 
Do you prefer that we call you for additional information? _____       If YES, provide phone number: ______________________
General remarks or explanations: ______________________________________________________________________________

_________________________________________________________________________________________________________

__________________________________________ _________________________                               _________________________________
Signature                                                    Date                                  Title, if Applicable

Cherokee County Public Schools is an equal opportunity employer and does not discriminate in employment on the basis of race, color, sex, religion,
                                                     creed, national origin, age or disability.
                                                                                                       CONFIDENTIAL REFERENCE FORM

                                                                                                                 Please check all that apply:
CHEROKEE COUNTY SCHOOL DISTRICT                                                                                  CERTIFIED EDUCATOR 
PO BOX 769, CANTON, GA 30169                                                                                     CLASSIFIED POSITION 
TELEPHONE       (770) 479-1871                                                                          SUBSTITUTE TEACHING POSITION 
        FAX     (770) 720-3490
                                                                               Applicant           ______________________________
To__________________________________                                           SS#                 ______________________________
       Name of Reference (Please Print)                                                                 Complete # optional, last 4 digits required
PLEASE DO NOT RETURN THIS FORM TO APPLICANT                                    Position            ______________________________

Please supply the Cherokee County School District with the requested information. I consent to the release of all reference
information and specifically release you from all liability arising from your giving the requested information about me. I waive all rights
that I may have to examine this reference information.
                                                                             ________________________________________________
                                                                               Applicant’s Signature                                          Date

The above applicant has applied for a position with the Cherokee County School District and has listed you as a reference. This
reference form will be included in the applicant’s file for review by school administrators. The reference is confidential and will not be
shared with the applicant. Your prompt reply is appreciated.
                                               I. THIS SECTION TO BE COMPLETED FOR ALL APPLICANTS
                                                            NOT          TOP 5%       TOP 20%     MIDDLE 50%      LOW 20%        LOWEST 5%
                   PROFESSIONAL TRAITS
                                                          OBSERVED     EXCELLENT       GOOD        AVERAGE          FAIR        UNACCEPTABLE
    Ability to work with administrators/peers
    Ability to work with parents/community
    General appearance
    Adaptability, dependability, reliability
    Displays tact and self control
    Positive attitude
    Personal initiative
    Energy level
    Verbal/written communication
    Prompt, neat, accurate reporting
    Learns skills easily
    Ability to accept criticism
    Takes pride in work
    Attendance, punctuality
    Observes safety rules
    Job performance unaffected by personal issues

    II. THIS SECTION TO BE COMPLETED FOR CERTIFIED EDUCATOR APPLICANTS ONLY (TEACHING, SERVICE OR LEADERSHIP)
    Care of room
    Creativity
    Enthusiasm for teaching
    Involvement in school activities
    Knowledge of subject matter
    Leadership ability
    Maintains appropriate discipline
    Organizational skills
    Potential for success
    Teaching strategies/skills

        Is candidate open-minded and receptive to suggestions?                            YES  NO 
        Would you hire this candidate to work with or near children?                      YES  NO 
        If candidate applied to you for a job, would you employ/re-employ this person? YES  NO 
Has candidate ever failed to be recommended, asked to resign, or given a letter of reprimand/concern? YES  NO 
Do you prefer that we call you for additional information? _____       If YES, provide phone number: ______________________
General remarks or explanations: ______________________________________________________________________________

_________________________________________________________________________________________________________

__________________________________________ _________________________                               _________________________________
Signature                                                    Date                                  Title, if Applicable

Cherokee County Public Schools is an equal opportunity employer and does not discriminate in employment on the basis of race, color, sex, religion,
                                                     creed, national origin, age or disability.

				
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