State of Iowa Standard Teacher Employment Application
Application Date:  	

Date Available:  	

Name: 	Social Security #:  	

Yes

Yes

U.S. Citizen:	Are you legally eligible to work in the United States?

Current Home Phone: 	Work Phone:  	

Current Address:  	

Permanent Address: 	Permanent Phone:  	

Position(s) for which you are applying:

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-

Yes

Are you available full time?	Are you willing to consider less than full time? Are you under a teaching contract for next year?
Where?  	

College	Location	Number of Hours
Beyond Highest Degree	Degree Major & Minor Fields	Dates Attended/ Graduated	

					

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High School Attended: 	Location:	 Have you applied for your Iowa Teacher License?		Iowa Folder Number:  	 Do you hold a license from another state?		If so, which state(s)?
What certifications, endorsements or approvals have you achieved (include coaching authorization)?

Education and/or other Employment (begin with current/most recent) *Teachers may include paid or volunteer activities other than classroom teaching and new teachers should include student teaching and other field experiences.

School District/Employer:  	 Address:  	

Supervisor’s Name:  			 Dates of Experience: 	to  	

Phone:		 Position:  	

Duties and Responsibilities (include coaching and/or extracurricular activities):

Reason for Leaving:  	

School District/Employer:  	 Address:  	

Supervisor’s Name:  		  Dates of Experience: 	to 	

Phone:	 Position:  	

Duties and Responsibilities (include coaching and/or extracurricular activities):

Reason for Leaving:  	

School District/Employer:  	 Address:  	

Supervisor’s Name:  		 Dates of Experience: 	to  	 

Phone:	 Position:  	 

Duties and Responsibilities (include coaching and/or extracurricular activities):

Reason for Leaving:  	

School District/Employer:  	 Address:  	

Supervisor’s Name:  		 Dates of Experience: 	to  	 

Phone:	 Position:  	 

Duties and Responsibilities (include coaching and/or extracurricular activities):

Reason for Leaving:  	

School District/Employer:  	 Address:  	

Supervisor’s Name:  		 Dates of Experience: 	to  	 

Phone:	 Position:  	 

Duties and Responsibilities (include coaching and/or extracurricular activities):

Reason for Leaving:  	

School District/Employer:  	 Address:  	

Supervisor’s Name:  		 Dates of Experience: 	to  	 

Phone:	 Position:  	 

Duties and Responsibilities (include coaching and/or extracurricular activities):

Reason for Leaving:  	
Military:

Active Duty:	to	Reserve Duty:	
Branch:	Branch:	
Location of Duty:	Obligation:	
Rank at Discharge:	Times of Current Training Duty:	
Type of Discharge:		

References: List at least three who have evaluated your teaching skills and abilities.

Name	Employer & Address	Position	Phone: Work and Home	

				

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Have you previously held a licensed position in an Iowa public school?
District?  	

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If yes, have you successfully completed an official probationary period in a public school district?

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If yes, what was the length of the probationary period?
Are you on a sex offender registry?

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Are you on the Department of Human Services’ child abuse registry?
Have you ever been convicted of a felony or misdemeanor (excluding traffic violations)? If yes, please provide date, incident city/state of charge:

Responding “yes” to any of the previous questions is not an automatic bar to employment. The date of the offense, and the relationship between the offense and the position for which you are applying will be considered.

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Are you able to perform, with or without reasonable accommodation, the essential job functions required of this position?

If no, explain:  	

Authorization and Verification

I hereby authorize that my former and/or current employer(s), professional colleagues, instructors or friends may provide any information requested by the search committee of the Centerville Community School District regarding my professional competence, performance and character.

I hereby certify that all application statements are true and complete to the best of my knowledge, and that, if employed, false statements herein shall be sufficient cause for dismissal. I understand that before any contract becomes effective or compensation is possible, a valid Iowa Teaching License must be filed with the Director of Human Resources. I also understand that all employees are required to have a physical examination as a condition of employment. I further understand that if I accept a
position with the Centerville Community School District, these statements are to become a part of my permanent record. In addition, because of the tremendous responsibility the Centerville Community School District has to its students and their families, I understand that a criminal background check will be conducted.

Signature of Applicant 	Date  	

Please print your name