Iowa Valley Community School District

IOWA VALLEY COMMUNITY SCHOOL DISTRICT 359 East Hilton Street Marengo, Iowa 52301-1620 319 642 7714

Application for Certified Position

Name: Date: Last First Middle

Address: E-mail: Street City State Zip

Phone: Fax #: Home Business Cell

Present Position: School District:

Position Desired: Date Available for Employment:

EDUCATIONAL RECORD (List in chronological order beginning with high school.) Name & Location of Institution Attended Year(s) Degree Major(s) Minor(s)

Do you hold, or are you eligible for an Iowa teaching license for this position? Yes No (Submit a copy of your current certification.)

List below all endorsements, approvals you have attained.

EDUCATIONAL HONORS, AWARDS (List in chronological order.) Name & Location of Institution Name of Award/Date Presented by

STUDENT TEACHING EXPERIENCE (List in chronological order. Include internships.) Dates Name & Location of School Grade Level/Subject Supervising Teacher

TEACHING EXPERIENCE (List in chronological order.) Dates Name& Location of School Grade Level/Subject Supervising Teacher To: Name:

From: Phone #:

Full-time or part- Reason for leaving (please be specific): time: To: Name:

From: Phone #:

Full-time or part- Reason for leaving (please be specific): time: To: Name:

From: Phone #:

Full-time or part- Reason for leaving (please be specific): time:

WORK EXPERIENCE OTHER THAN TEACHING (Include military service.) Begin/End Dates Name & Location of Employer Position or Rank Reason for Leaving/Discharge

PROFESSIONAL REFERENCES As an applicant, it is your responsibility to provide the Iowa Valley CSD the names of at least four professional reference sources.

If you are a beginning teacher, list the individuals who supervised your student teaching, as well as others associated with your evaluation. If you are an experienced teacher, please provide references from the principals and superintendents in the school district(s) in which you have taught within the last five years. If you have not taught within the last five years, please provide reference from your most recent teaching position.

REFERENCES (Names of four persons who can discuss your experience and qualifications in detail.) Name Official Position Phone Number Business Home Cell Business Home Cell Business Home Cell Business Home Cell

Please list any extra-curricular activities for which you are qualified and are willing to serve as coach and/or advisor.

EMPLOYMENT STATUS Have you previously held a licensed position in an Iowa public school district? If so, where?

Are you available full time? Are you willing to work less than full time? Yes  No  Yes  No  If you are currently under contract to an Iowa school district, can you be released if you are offered a position in another school district? Yes  No  If no, please explain:

Why do wish to teach in the Iowa Valley Community School District?

BACKGROUND CHECK AND INFORMATION In addition to the following information, a background check will be made by the District.

If additional space is needed, begin your explanation here and attach additional sheets and clearly identify as “background check and information”:

“ YES” answers to the following questions will not necessarily result in denial of an offer of employment. Administration will consider all the circumstances, including the date and nature of events that have led to the actions described below. Your written explanation will assist the board in determining your eligibility and suitability for an offer of employment.

 Have you ever been convicted of, admitted committing, pleaded no contest, or are you awaiting trial for any crime (excluding only minor traffic violations not involving any allegation of intoxication or reckless driving)? You must answer “YES” if true, even if the matter was later dismissed, deferred, reversed, or vacated. If you answer “YES” you must provide dates of the proceedings, the name and address of the court where the proceedings occurred, a statement of the accusation against you and the final disposition of the case(s). Yes No Explanation:

 Have you ever been dismissed (fired) from any job, or resigned at the request of your employer, or while charges against you or an investigation of your behavior were pending? You must answer “YES” if true, even if the matter was later resolved. If you answer “YES” you must provide the date of termination of employment, the name, address and telephone number of the employer(s) and a statement of the alleged reasons for termination. Yes No Explanation:

 Have you ever had any license or certificate of any kind (teaching certificate or otherwise) revoked or suspended, or have you in any way been sanctioned by or is any charge or complaint now pending against you before any licensing, certification or other regulatory agency or body, public or private? If you answer “YES” you must provide the dates of proceedings, name, address and telephone number of the agency or body where proceedings took place, a statement of the accusations against you, the final disposition and/or status of the charge or complaint. Yes No

Explanation:

 Are you now being investigated for any alleged misconduct or other alleged grounds for discipline by any licensing, certification or other regulatory body (teacher certification or otherwise) or by your current or any previous employer? If you answer “YES” you must provide the name, address and telephone number of the employer or licensing body and statement of the accusation against you. Yes No Explanation:

VERIFICATION STATEMENT (Please read carefully and sign the statement below.)

The information in the Application for Employment is true, correct, and complete to the best of my knowledge. I certify that I have answered all questions to the best of my ability and I have not withheld any information that would unfavorably affect my application for employment. I acknowledge that any misrepresentation or omission of any fact in my application, resume, or any other materials, or during any interviews, may be the cause for my rejection from employment or may result in my subsequent dismissal if I am hired.

Signature Date

My signature below authorizes the school district to conduct a background investigation and authorized release of information in connection with my application for employment. This investigation may include such information as previous employers and educational institutions, personal and professional references, criminal or civil convictions, and driving records. I waive my right of access to such information, and without limitations, hereby release the school district and the reference source from any liability in connection with its release or use.

Signature Date

APPLICANT’S FILE MUST INCLUDE:  A letter of application stating personal qualifications, experiences, and reasons for interest in the position.  A completed and signed official application form and current resume.  A copy of your current teaching certificate.  Three current letters of recommendation. Beginning teachers should have a copy of their college credential file sent to us by the placement office.  A personal interview is required before an applicant is recommended for employment.  Upon acceptance of a position in the district, the applicant must provide a complete, original transcript of college credits.

Please Direct All Inquiries, Applications and Supporting Materials To: Superintendent’s Office Iowa Valley Community School District 359 East Hilton Street Marengo, Iowa 52301-1620 319 642 7714 Phone 319 642 3023 Fax Website: www.iowa-valley.k12.ia.us

The Iowa Valley Community School District does not discriminate on the basis of race, color, age, national origin, religion, sex, disability, sexual orientation, gender identity, or marital status in admission or access to, or treatment in, its hiring and employment practices.