TEACHER APPLICATION LAKE COUNTY SCHOOLS 819 McBride Street Tiptonville, TN 38079 NAME: _____________________________________________________________________________________ (First) (Middle/Maiden) (Last) Date: _______________________Social Security #: _________________________DOB: ____________________ Please attach a recent picture to this application. PERSONAL DATA: Present Address: ______________________________________________________________________ (Street) (City) ______________________________________________________________________ (State) (Zip Code) Email address if available: _______________________________________________________________ Telephone: ___________________________________________________________________________ (Home) (Cell) (Business) Permanent Address:____________________________________________________________________ (Street) (City) _______________________________________________________________________ (State) (Zip Code) Have you ever been convicted of a felony? ____________________ if yes, please explain: ________________ ___________________________________________________________________________________________ POSITION FOR WHICH APPLICATION IS MADE: Elementary: _________________________________________________ (specific grade or grade span) Middle School: ______________________________________________ (specific grade and/or subjects) High School: ________________________________________________ (specific grade and/or subjects) Vocational: _________________________________________________ (specific grade and/or subjects) Other position: _______________________________________________ Note: Applicants for coaching positions should include a summary of their athletic experience. 1 CERTIFICATION: Type(s) of Tennessee Teacher’s Certificate(s) Held: _________________________________________________________________________ Expected: _____________________________________________________________________ Certification Number(s): ________________________________________________________________ Date of Expiration: _____________________________________________________________________ Grade Level(s): ________________________________________________________________________ Area(s) of Endorsement: ________________________________________________________________ ________________________________________________________________ Career Ladder Level: ___________________________________________________________________ Have you acquired tenure In Tennessee? _________________________________________________________ If yes, in what school district? ____________________________________________________________ Date you would be available for employment: _____________________________________________________ EDUCATIONAL PREPARATION: Earned degree(s): ______________________________________________________________________ GPA based on a 4.00 scale _______________________________________________________________ If you are applying for a middle school or high school position, what is your GPA in your area of endorsement (based on a 4.00 scale): ____________________________________________________________ SCHOOLS ATTENDED: School, College or Address Dates Attended Major University Student Grade Level(s) Teaching/Practicums Taught Subject(s) Taught 2 School System Degree or Date of Diploma Graduation University Cooperating Supervisor Teacher(s) TEACHING EXPERIENCE: Please list in order beginning with the most recent. If you have not been previously employed as a teacher, please check here ______ and go to the next section. Position Name of District City and State Specific Years Employed OTHER RELEVANT EMPLOYMENT OR EXPERIENCE: Position Employer City and State Specific Years Employed NUMBER OF COLLEGE HOURS EARNED IN READING: _______________ NUMBER OF COLLEGE HOURS EARNED IN MATHEMATICS: ______________ BACKGROUND INFORMATION: If you answer “yes” to any of the following questions, please attach a written response describing, in detail, an explanation of the circumstances involved. 1. Have you ever been convicted of a violation of law other than a minor traffic violation: The term “conviction” includes any conviction, a guilty plea, a plea of nolo contendere or no contest, a suspended sentence, a deferred sentence, a deferred judgment, or a finding of guilt by a jury or judge. _____yes _____no 2. Have you ever been terminated or discharged or resigned at the request of your employer from any job related to preK-12 education? _____yes _____no 3. In connection with your professional responsibilities, have you ever been the subject of a complaint or been disciplined by a court or a licensing board of any state? _____yes _____no 4. Are you currently under investigation by any regulatory body for any alleged misconduct or other alleged grounds for discipline? _____yes _____no 3 REFERENCES (Professional Only) The applicant is responsible for contacting those persons listed below to have them complete and send to this office the form “Confidential Teacher Appraisal” Name Complete Address Occupation Phone number 1. 2. 3. 4. ADDITIONAL INFORMATION: 1. Have an official copy of your transcript(s) forwarded from the college or university to this office. 2. Request your college Placement Office (if your college offers this service) to forward your credentials to this office. 3. Documents filed in support of this application will not be returned. 4. This application, along with supportive documents, should be returned to: Lake County Board of Education 819 McBride Street Tiptonville, TN 38079 CHAPTER 178, THE PUBLIC ACTS OF 1973, TENNESSEE CODE ANNOTATED, SECTION 49-5-406 requires the following: (Please mark either HAVE or HAVE NOT for each choice below) I further certify that I (HAVE or HAVE NOT) been convicted of a misdemeanor or felony in any state of the United States. If HAVE is indicated, explain fully the details of each such conviction on a separate sheet of paper. I further certify that I (HAVE or HAVE NOT) been dismissed from any previous employment for improper or unprofessional conduct, inefficient service, neglect of duty, incompetence, or insubordination as the same are defined in Section 49-5-501 of the Tennessee Code. If HAVE is indicated, explain fully the details of each such dismissal on a separate sheet of paper. The employer’s non-renewal of a yearly contract need not be indicated unless the non-renewal was for cause as listed above. If my most recent employer were another Tennessee public school system and if my termination were voluntary, I hereby certify that my resignation was, or will be, submitted at least 30 days prior to the beginning date stated hereon; or, if within 30 days, that the previous board has waived its right to such notice. A copy of my letter of resignation or of the said board action is attached or will be provided. I understand that misrepresentation of any of these certifications may subject me to the penalties prescribed in Section 49-5-406 of the Tennessee Code. I, the undersigned, hereby certify that the foregoing information is true and correct. I fully understand that falsification of this application will be cause for rejection of the application and/or discharge. Further, I hereby agree to release all investigative records to the Lake County Board of Education for examination for the purposes of verifying the accuracy of criminal information and to supply a fingerprint sample and submit t a criminal history records check to be conducted by the Tennessee Bureau of Investigation. I certify that all applicable questions on this application have been completed and that the information provided is accurate. I understand that withholding information or providing inaccurate information may be grounds for invalidating a contract. Full Name (printed) _____________________________________ Signature ____________________________ 4 Address_______________________________________ City _____________________ State ____Zip_________ Phone number (___) ____-_______ Date: ________________________________________ The Lake County Board of Education is an Equal Opportunity employer. This district does not discriminate based on gender, race, national origin, religion, creed, age, marital status, sexual orientation, or disability. Briefly write a statement of your teaching philosophy below: 5