School Union 133

69 Augusta Road

Whitefield, ME 04353-3232

(207) 549-3261

APPLICATION FOR SUBSTITUTE TEACHING

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:

_________________________________

Name: _________________________________

Social Security No. ____ - ____ - ____

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:

No.of Years

COLLEGE/UNIVERSITY ATTENDED

Degree Awarded

Attended

Grade Point Average

_________________________________

_________

________________

_________________________________

_________

________________

_________________________________

_________

________________

_________________________________

_________

________________

CERTIFICATION: List Certification(s) you hold and provide copies of such certification.

Type:

State

Date Issued

Date of Expiration

_________________________________

_________

________________

_________________________________

_________

________________

_________________________________

_________

________________

EXPERIENCE: Please list previous teaching/substituting experience. Please attach a copy of your RESUME.

Grade/Subject

Position

Employer Tel. No.

Dates: From-To

__________________________________________________________________________________________________________________

AREAS OF INTEREST:

1. Please indicate the grade level(s) at which you are interested in substitute teaching:

K-2

3-5

6-8

Special Education

2. Please circle the school(s) preference(s). Palermo

Somerville

Windsor

3. Please circle the areas you enjoy teaching most or indicate a specialty area of yours.

Art

Music

Physical Education

Math

Science

Eng/Lit.

Other

4. Please indicate any personal time restraints: i.e.) available on Tues, Wed & Thurs only, or available Sept through April only.

___________________________________________________________________________________________________

REFERENCES: Please provide (3) three references who are not related to you, who are familiar with your work as a teacher,

substitute or who know of your experience working with youth. Please attach their letters of reference.

Name:

Address

Telephone No.

______________________________

____________________________________

_______________________

______________________________

____________________________________

_______________________

______________________________

____________________________________

_______________________

BACKGROUND:

1. Have you ever been disciplined, discharged, or asked to resign from a prior position?

Yes______No______

2. Have you ever resigned from a prior position after a complaint had been received

against you or your conduct was under investigation or review?

Yes______No______

3. Has your contract in a prior position ever been non-renewed?

Yes______No______

4. Have you ever not been nominated for re-employment in a prior position or ever had

your nomination for re-employment not be approved?

Yes______No______

5. Have you ever been charged with or investigated for sexual abuse or harassment

or another person?

Yes______No______

6. Have you ever been convicted of a crime (other than a minor traffic offense)?

Yes______No______

7. Have you ever entered a plea of guilty or “no contest” (nolo contendere) to any crime

(other than a minor traffic offense)?

Yes______No______

8. Have you ever had a professional license or certificate suspended or revoked in any

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

professional license or certificate in any state?

Yes______No______

9. Has any court ever deferred, filed or dismissed proceedings without a finding of 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 any crime (other

than a minor traffic offense)?

Yes______No______

10. If you have answered YES to any of the previous questions, please provide full details below including with respect to

court actions, the date, the offense in question and the address of the court involved. Attach additional sheets if

necessary. Conviction or other disposition of a crime is not necessarily an automatic bar to employment.

_____________________________________________________________________________________________________

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SIGNATURE:

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 processed

by any state, local or federal agency. I further authorize those 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 provision 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, it’s 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. I give my consent to this disclosure.

______________________________

Signature & Date

APPLICATION FOR SUBSTITUTE TEACHING 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 College transcripts enclosed. _______

Copy of Maine Teaching and CHRC/Fingerprinting certificate(s). _____

Resume. _____

Three letters of reference. _____

YES questions from the Background section fully explained. _____

___________________________________________________________________________________________________________

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.

10/05

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