IRWIN COUNTY BOARD OF EDUCATION P. O. BOX 225 OCILLA, GEORGIA 31774 For Office Use Only APPLICATION FOR EMPLOYMENT Date Hired Date Applied Date Interviewed Date available for employment Name SSN Permanent Address Mailing Address (if different) Phone (Home) (Cell) For position as PLEASE ATTACH A RESUME AND INCLUDE THREE REFERENCES. Yes No Have you completed The Teacher Insight Interview? University/College(s) administering degrees: Undergraduate Graduate Do you presently hold a Valid Teaching Certificate? Yes No Applied State Level Field Have you passed the appropriate Georgia Certification test? Yes No FieldsTaken: PRAXIS I: Yes No Awaiting Results Fields Taken PRAXIS II: Yes No Awaiting Results Fields Taken GACE: Yes No Awaiting Results Fields Taken Have you ever been dismissed from employment with a school system, or asked to resign in lieu of dismissal? Yes No Have you ever received an unsatisfactory annual performance evaluation? Yes No If yes, explain: Have you ever had a teaching certificate or credential denied, revoked or suspended? Yes No If yes, explain: Areas of certification and concentrations Grade and/or subject preferences VIEWPOINT Please use additional sheets to express in your own handwriting your views on a current development or issue in education or in your specific subject field. CRIMINAL CONDUCT Have you ever been arrested for any crime or been named in an indictment, accusation, or special presentment of any offense, other than a minor traffic violation? Yes No If “yes,” attach an explanation. Have you ever been convicted of any crime, entered a plea of guilty, nolo contendere, suffered first offender adjudication, or any similar criminal, quasi-criminal or adjudications? Yes No If the answer is “yes,” state the name and address of the court, the date of the alleged offense, a description of the charges, and an explanation of the final action taken, including any fines, probation, imprisonment, first offender adjudication, or similar disposition. CRIMINAL RECORD CHECK CONSENT and AFFIRMATION I understand and agree to a criminal record check as provided by O.C.G.A. 20-2-211, by the policies and rules of the state board of education, and by this board of education. I agree to sign the appropriate forms which the law enforcement agency may require to give consent for a criminal record check through the National Crime Information Center and the Georgia Crime Information Center. If offered a contract of employment, I understand that I will be issued only a temporary contract pending the outcome of a criminal record check. I understand that fingerprinting and applying for a background check will take place at the Ocilla Police Department and Irwin County Detention Center, and that I will be responsible for all charges incurred. I understand that the Irwin County School System may contact any or all of the references, as well as other principals, supervisors, or acquaintances. I understand that any misrepresentation, falsification or omission of facts to include criminal record will be sufficient cause for cancellation of the application or termination of employment. I understand that the information given herein becomes a legal part of the contract should I become employed by the Irwin County School System. I further understand that this application and all materials related to it become the property of the Irwin County School System and are not available to the applicant. I hereby affirm that the information given by me in this application is true and complete to the best of my knowledge and belief. SIGNATURE Date The Irwin County Board of Education does not discriminate on the basis of race, age, color, national origin, sex or disability in education programs, activities and employment.