Southwest Plains Regional Service Center

Application Form

CERTIFIED POSITIONS

Rhonda McNeil, Board Clerk 900 Lark Avenue P.O. Box 1010 Sublette, KS 67877 1 620-675-2241 PERSONAL INFORMATION

Name: Phone: Home Address: E-Mail Address: Business Address: Phone: Do you currently hold a valid 5-year Kansas Teaching or Administrator Certificate? Do you hold current certificates in other states? If so, please list states: Have you ever been convicted of a felony or a crime involving moral turpitude? If yes, please explain: Condition of your heath for the past three years? Number of days you have missed work in the last three years due to illness?

WORK EXPERIENCE

Please list your work experience beginning with your current position. Name of Address Position From/To Salary organization

Are you currently under contract? Yes no If yes, when does your contract expire?

2 AWARDS, HONORS AND MEMBERSHIPS

Please list educational and personal awards, honors and memberships.

EDUCATION

Date of High School Graduation ______Name of High School ______

Please list your post-secondary education beginning with your most recent relevant work.

Institution Address From/To Degree/Cert

Undergraduate Major: Hours: Minor Hours

Graduate Major: Hours: Minor Hours

May we contact your present employer for information regarding your work performance?

3 REFERENCES

Please list three professional and two personal references that may be contacted. Name E-mail Address Home Phone Business Phone Relationshi p

4 ADDITIONAL INFORMATION

Please respond to the following statements and questions in your personal handwriting. (Please mail pages 5 & 6 to Rhonda McNeil, Board Clerk, if you are submitting the remainder of this application via e-mail.)

1. Are there any conditions that might preclude you from working for SWPRSC for at least 2 years? If so, please explain.

2. Please state your reasons for seeking employment with SWPRSC.

3. Briefly state your educational philosophy and how it relates to education in the twenty- first century.

5 I certify the above information to be true, and understand that falsification could be grounds for termination.

I expressly authorize the release to Southwest Plains Regional Service Center any records of information which may refer or relate to this application for employment, including, but not limited to, records of education institutions, enforcement or criminal justice agencies, agencies maintaining child abuse records, and previous employers. I hereby release and discharge SWPRSC, and any responsible persons(s) employed by SWPRSC, from any and all claims and liability which I may have or ever claim to have relating to information provided SWPRSC as a part of this application for employment. YES: NO

(Signature of Applicant) (Date)

Southwest Plains Regional Service Center does not discriminate on the basis of sex, race, color, national origin, handicap, or age in admission to, or treatment of employment in its programs or activities. Any questions regarding the service center’s compliance with Title VI, Title IX, or Section 504 may be directed to the Executive Director, at 620-675-2241, P.O Box 1010, Sublette, KS 67877 or to the Assistant Secretary for Civil Rights, USD Department of Education.

Additional Submissions: Candidates are asked to also submit the following items to complete the application process.

1. Letter of application 2. Credentials or three letters of recommendation 3. Current certificate or license 4. Copy of current transcripts 6 7