Certified Application

Certified Application

BARRY WALLER, SUPERINTENDENT
117 EAST WESLEY AVENUE, LYONS, GA 30436
Telephone:912-526-3141 Fax:912-526-3291
Application for Employment-Certified

Toombs Logo

DATE:

Last Name

First Name

Middle Name

Maiden Name
Present Address:(Street OR P.O. Box)

City

State

Zip Code

Birthday

Telephone #
Name as it Appears on Social Security Card:  
POSITION(S) DESIRED:
Teacher
Media Specialist
Special Education
Administrator
Counselor
Special Ed. Area
Specialist
Other
Level Preferred:
Early Childhood
Elementary
Secondary
If K-8: Indicate Grades, If Secondary, Indicate Fields of Certification:
1. 2.
3. 4.
Secondary: Indicate Subjects in which you have 20 Quarter hours or more:
1. 2.
3. 4.
Professional Preparation:
Colleges or Universities AttendedDatesDegree
List of College activities engaged in and honors received if recent graduate. If not recent graduate, list civic and professional activities:
Certification Information:
Do you hold, or are you eligible for a current Georgia Teacher's Certificate? Yes No
Do you hold a certificate from another state? Yes No
If Yes to either, list type of certificate(s):
Certificate Number: Retirement Number:
Fields or Grades Certified to Teach:
Undergraduate Major:
Teaching Experience:
School & AddressGrades/SubjectYear(s)Month/Year
Employment Status:
Have you ever failed to be re-elected? Yes No
If Yes, Where? Why?
Have you ever broken a contract with an employer? Yes No
If yes, give details
Miscellaneous Information:
Are you a retired GA Educator? Yes No
May we contact your past and/or present employer? Yes No
Please indicate by your signature your permission to check confidential fields regarding your past employment record:
Can you come for an interview? Yes No
Date you could begin work?
Have you had student teaching? Yes No
DatesSupervisorSchoolAddress
References: List the names of three persons, not related to you, who have a definite knowledge of your qualifications and work performance in the position for which you are applying. Be sure to include your former administrators if you are an experienced teacher.
Name: Phone#:
Position: Address:
 
Name: Phone#:
Position: Address:
 
Name: Phone#:
Position: Address:
Tell why you entered the teaching profession: (Applicant Must Complete)
Have you ever been convicted of a felony or any crime involving moral turpitude? Yes No
If Yes, Please explain

I understand that any false answer or statement or implication made by me on this application shall be considered sufficient cause for denial of employment.

Signature

Date

 

DO NOT WRITE IN THIS SPACE

 

Date Received:

Acknowledged:

References:

Contract:

Assigned:

The Toombs County Board of Education is an equal opportunity employer. The board does not discriminate on the basis of race, color, sex, age, national origin or handicap in its educational programs, activities, or employment policies.



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