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SHEEPSCOT VALLEY SCHOOL UNION #133

APPLICATION FOR ADMINISTRATION POSITION

Palermo, Somerville & Windsor Schools

School Union #133 does not discriminate in the operation of its educational and employment policies and will honor all appropriate laws relative to discrimination.

Date: _______________________ Position(s) applying for: ___________________________________________

Name: _____________________________ Location: _______________________________________________________

Social Security No: ___________________ _______________________________________________________________

When will you be available? ____________ _______________________________________________________________

Physical Address: __________________________________________________Phone: __________________________

Mailing Address: __________________________________________________ Phone: __________________________

EDUCATION: Transcripts, including grades, from all college(s)/University(s) attended must be provided. It is essential that this section

be completed accurately.

College/University Attended Degree Awarded

____________________________________________________________________________________________________________________

Undergraduate grade point average? _______

Graduate grade point average? _______

CERTIFICATION: List certification(s) you hold and provide copies of certifications including CHRC/fingerprinting.

Type State Date Issued Date of Expiration

____________________________________________________________________________________________________________________

If you do not hold a Maine Certificate, for what type of Maine Certificate are you applying and eligible?

Note: Candidates who do not hold Maine Certification should direct an inquiry to the Maine Department of Education, Division of

Certification and Placement, Augusta, Maine, 04333

7/06

EXPERIENCE: A resume’ must be provided. In addition to educational background and work experience, include extracurricular activities

in which you have been involved. Please list below positions held, employer, and dates of employment for the past ten years. Please

account for any gaps in employment on a separate page.

From: (Month/Year) To: (Month/year) Position Employer

BACKGROUND:

Have you ever been disciplined, discharged, or asked to resign from a prior position? Yes _______ No _________

Have you ever resigned from a prior position after a complaint had been received against Yes _______ No _________

you or your conduct was under investigation or review?

Has your contract in a prior position ever been non-renewed? Yes _______No _________

Have you ever not been nominated for re-employment in a prior position or ever Yes _______ No ________

had your nomination for re-employment not be approved?

Have you ever been charged with or investigated for sexual abuse or harassment Yes _______ No ________

of another person?

Have you ever been convicted of a crime (other than a minor traffic offense?) Yes _______ No ________

Have you ever entered a plea of guilty or “no contest” (nolo contendere) to any crime Yes _______ No ________

(other than a minor traffic offense)?

Have you ever had a professional license or certificate suspended or revoked in Yes _______ No ________

any state, or have you ever voluntarily surrendered, temporarily or permanently,

a professional license or certificate in any state?

Has any court ever deferred, filed or dismissed proceedings without a finding of Yes _______ No ________

guilty and required that you pay a fine, penalty or court costs and/or imposed a

requirement as to your behavior or conduct for a period of time in connection with

a crime (other than a minor traffic offense) ?

If you have answered YES to any of the previous questions, provide full details on an additional sheet including, with respect to court actions,

the date, offense in question, and the address of the court involved. Conviction or other disposition of a crime is not necessarily an automatic

bar to employment.

REFERENCES: Please provide (3) references that are not related to you, who are familiar with your work as a teacher, or who know of your experience

working with youth. Please attach their letters of reference.

Name Position Address Phone

________________________________________________________________________

____________________________________________________________________________________________________________________

My signature below constitutes authorization to check my employment history, including without limitation, criminal arrest and conviction record checks,

reference checks, and release of investigatory information possessed by any state, local or federal agency. I further authorizethose persons, agencies,

or entities that School Union #133 contacts in connection with my employment application to fully provide School Union #133 any information

on the matters set forth above. I expressly waive in connection with any request for or provisions of such information, any claims, including without

limitation, defamation, emotional distress, invasion of privacy, or interference with contractual relations that I might otherwise have against School Union #133,

its agents and officials or against any provider of such information.

I understand that information submitted in and with this application may be disclosed to a screening and/or interviewing committee, which may

include board members, administrators, other staff, and members of the community. I give my consent to this disclosure.

______________________________________

Signature/Date

APPLICATION FOR ADMINISTRATIVE POSITION CHECK LIST:

The completed employment application cannot be evaluated unless all of the following materials have been provided:

_____ Application form fully completed

_____ Copies of Transcripts(s)

_____ Copy of Maine Certification(s) (Fingerprinting and Teaching or Nursing)

_____ Resume’

_____ Gaps in employment in the past ten years explained

_____ YES to any of the questions in the Background section explained

_____ Three letters of reference

_____ Application signed

NOTE: ALL APPLICATION MATERIALS BECOME THE PROPERTY OF SCHOOL UNION #133. NONE WILL BE RETURNED. PROVIDING ANY FALSE OR MISLEADING

INFORMATION ON THIS APPLICATION OR IN THE APPLICATION OR EMPLOYMENT SCREENING PROCESS SHALL BE FULLY SUFFICIENT GROUNDS TO REFUSE

TO EMPLOY THE APPLICANT OR, IF THE APPLICANT HAS BEEN EMPLOYED, TO IMMEDIATELY DISMISS THE APPLICANT/EMPLOYEE.