Lyons Unified School District #405

UNIFIED SCHOOL DISTRICT #405-LYONS 800 South Workman * Lyons, Kansas 67554 * Telephone: 620-257-5196

PROFESSIONAL APPLICATION

Date ______Social Security Number______Telephone______

Last Name ______First Name ______Middle ______

Address ______City______State ______Zip______

Level or position sought: K-5 ______6-8 ______9-12______Special Education ______

Kansas Certification (Please attach a copy of current Kansas certificate. If one is not available, please complete the following.)

Level Endorsements Description of Subject ______

Grade, subject, or area of specialty desired:

1st choice ______2nd choice ______3rd choice ______

TEACHING EXPERIENCE

Grade or Name of College, District From To Subjects School, and City (Year) (Year) Reason for Leaving

As of the date of this application, I have a (check the highest):

Bachelor’s Degree ____ Bachelor’s Degree + 15 semester hours ____ Bachelor’s Degree + 30 semester hours at least 15 graduate ___ Bachelor’s Degree + 40 semester hrs. graduate _____ Master’s Degree ____ Master’s Degree + 15 semester hrs. graduate _____ Master’s Degree + 30 semester hrs. graduate _____ Master’s Degree + 45 semester hrs. graduate _____ Doctor’s Degree _____

Secondary School, College, & University City & State Years Attended Year Grad Degree

Date available for employment ______Are you under contract for next year? ______

Activities which you can sponsor or coach (football, basketball, music, drama, etc.) 1. ______4. ______2. ______5. ______3. ______6. ______

List high school, college, and teaching experience in the above. ______Have you previously held a teaching position with us? ______If yes, give dates and names under which employed, if different from this application ______

Have you been denied a teaching certificate/license or had your teaching certificate /license suspended or revoked? ______If yes, check the action taken denied ______suspended ______revoked ______Which State(s) ______

Please specify any language (other than English) that you are proficient in: ______

Are you legally authorized to work in the United States of America? ______

Special skills or interests: ______

REFERENCES: (should include the supervisor, principal, and any other professional educator in a position to judge your teaching ability.)

Name Mailing Address Telephone Position Held

AGREEMENT 1. I certify that the information provided by me in this application is true and complete. I understand that any misstatement, falsification, or omission of information is grounds for refusal to hire or, if I am hired and the same is discovered thereafter, termination. 2. I authorize any of the persons or organizations referenced in this application to give you any and all information concerning my previous employment, education, or any other information, personal or otherwise, with regard to any of the subjects covered by this application, and I release all such parties from all liability for any damages that may result from furnishing such information to you. I authorize any background checks by any third party. 3. I authorize you to request, receive, and verify all information given on this application and I release you from all damages that may result from your doing so. 4. I authorize you to conduct a criminal and civil background investigation using any and all methods necessary to successfully complete such investigation and I release you from all liability for any damages that may result from your doing so. 5. I further agree to observe all rules, regulations, and policies of the District now in force and effect or as they may change during my employment, if I am employed by the District.

______Signature of Applicant Date

Office\Forms\Certified Application (BOE Approved 6/11/09)

LYONS UNIFIED SCHOOL DISTRICT #405 800 S. WORKMAN LYONS, KS 67554 Gary L. Sechrist, Superintendent

USD 405 Phone: (620) 257-5196 Focusing on improving Fax: (620) 257-5197 student learning. Authorization and Disclosure

As part of the application process for employment at __USD 405 - Lyons______, I understand that they and/or its agents may conduct an investigation of my personal information. The investigation might include, but is not limited to names and dates of previous/current employment, work experience, workers' compensation claims, criminal history records (from state, federal and other agencies), motor vehicle records, military records, names and dates of education, credit history, and bankruptcy records. I understand that these records may be used for the eligibility of my employment. I authorize without reservation the full release of these records and for National Screening Bureau and/or its agents contacted by National Screening Bureau to obtain information. In addition, I release and discharge National Screening Bureau, and all of its agents and associates, any expenses, losses, damages, liabilities, or any other charges or complaints for the investigative process.

I also authorize the full release of the information described above, without any reservation, throughout any duration of my employment at the above stated company.

I also certify that all information provided is correct on the application and my resume to the best of my knowledge. Any false statements provided will be considered just cause for termination of employment.

Upon Request, National Screening Bureau will supply a copy of my report and my rights under the Fair Credit Reporting Act. Requests may be directed to: National Screening Bureau, 200 W Douglas, Suite 600, Wichita, KS 67202 or by contacting us at 1-877-263-4405. Signature: ______Date: ______I have received a copy of “A Summary of your Rights”

The following must be filled out completely for your application to be considered. Last Name 1First Name 2Middle Name 3Other Names Used

4Home Address 5City 6State 7Zip 8 9Previous Address 10City 11State 12Zip 13 14Phone # 15S 17Date of Birth 18Social Security 20Drivers ex 24M 25D YYYY # License # 16M M D 19 21 F *NOTE: Date of birth, sex, and race are being 29Race 30State Drivers License was issued in: requested only for purposes of identification in 31 obtaining accurate retrieval 32 28