Complete Application Package Consists Of

Application Deadline: Noon, March 19, 2015

Personal Information Last Name:Click here to enter First Name: Click here to enter Middle Name: Click here to enter text. text. text.

Social Security #: Click here to enter text.

Street Address: Click here to enter text.

City/State/Zip: Click here to enter text.

Telephone Numbers: (H): Click here to enter text. (C): Click here to enter text. (W): Click here to enter text.

Email Address: Click here to enter text. Date Available for Employment:Click here to enter text. Do you have a Kentucky certificate for school superintendent? Click here to enter text. If no, do you hold a valid superintendent’s license for any other states? Please name: Click here to enter text. Have you ever been convicted of a felony? Click here to enter text. If yes, please explain: Click here to enter text. Have you ever been dishonorably discharged from the military? Click here to enter text. Have you ever been known by any other names? Click here to enter text. If yes, please list: Click here to enter text.

2 Have you ever declared personal or business bankruptcy? Click here to enter text.

Current School District Information

Name of District:Click here to enter text. Your Position: Click here to enter text. Student Enrollment: Click here to District Budget: Click here to Total # Employees: Click here to enter text. enter text. enter text.

Major Responsibilities: Click here to enter text. Significant Accomplishments: Click here to enter text.

Personal Education History

High School:Click here to enter text. Location:Click here to enter text. Major Course or Subject:Click here to enter text. Start Date:Click here to enter text. End Date: Click here to enter text. Graduated?Click here to enter text. Degree:Click here to enter text.

College: Click here to enter text. Location: Click here to enter text. Major Course or Subject: Click here to enter text. Start Date:Click here to enter text. End Date: Click here to enter text. Graduated?Click here to enter text. Degree:Click here to enter text.

College: Click here to enter text. Location: Click here to enter text. Major Course or Subject: Click here to enter text. Start Date:Click here to enter text. End Date: Click here to enter text. Graduated?Click here to enter text. Degree:Click here to enter text. Professional Experience

2 3 Please start with present or most recent. List all previous employers.

# of Years Click here to enter text. Start Date:Click here to enter text. End Date: Click here to enter text. Position Title:Click here to enter text. Organization, Address: Click here to enter text. Reason For Leaving: Click here to enter text.

# of Years Click here to enter text. Start Date:Click here to enter text. End Date: Click here to enter text. Position Title:Click here to enter text. Organization, Address: Click here to enter text. Reason For Leaving: Click here to enter text. # of Years Click here to enter text. Start Date:Click here to enter text. End Date: Click here to enter text. Position Title:Click here to enter text. Organization, Address: Click here to enter text. Reason For Leaving: Click here to enter text.

# of Years Click here to enter text. Start Date:Click here to enter text. End Date: Click here to enter text. Position Title:Click here to enter text. Organization, Address: Click here to enter text. Reason For Leaving: Click here to enter text. Professional References

Provide the information below of five people who can speak of your professional competency and character.

Name: Click here to enter text. Type of Acquaintance: Click here to enter text. Address: Click here to enter text. Phone: (H)Click here to enter text. (W)Click here to enter text.

Name: Click here to enter text. Type of Acquaintance: Click here to enter text.

4 Address: Click here to enter text. Phone: (H)Click here to enter text. (W)Click here to enter text.

Name: Click here to enter text. Type of Acquaintance: Click here to enter text. Address: Click here to enter text. Phone: (H)Click here to enter text. (W) Click here to enter text.

Name: Click here to enter text. Type of Acquaintance: Click here to enter text. Address: Click here to enter text. Phone: (H)Click here to enter text. (W)Click here to enter text.

Does the Board of Education or its agents have your permission to contact your current employer? Click here to enter text.

Does the Board of Education or its agents have your permission to contact the above named persons? Click here to enter text.

Have you ever been dismissed from a relevant position, had disciplinary charges against you, or been denied or had professional licensure revoked or suspended? Click here to enter text.

Have you ever been convicted on a drug or alcohol related traffic offense? Click here to enter text.

Community Activities (voluntary and community service clubs, etc) Click here to enter text.

Give two or three personal attributes that assure your success as a superintendent. Click here to enter text. What are the most important qualities that make you the best choice as superintendent? Click here to enter text.

Identify two of your major professional accomplishments. Click here to enter text.

Describe your professional experience with each of the following:

Financial Planning: Click here to enter text.

Facilities Planning:

4 5 Click here to enter text.

Curriculum: Click here to enter text.

Personnel Decisions: Click here to enter text.

Strategic Planning: Click here to enter text.

Community Relations: Click here to enter text.

SIGNATURE FORM

By typing my name in the signature field below, I certify that the information in this application is true and accurate to the best of my knowledge and belief.

I hereby authorize the Board of Education or its agents to conduct such investigations, including criminal and credit records, as the Board deems necessary. I understand that giving false or misleading information, either oral or written, may result in denial or termination of my employment.

Electronic Signature: Click here to enter text.

Date: Click here to enter a date.