Zachary Community School Board
Application for Certified Position
Application Date Application For
Zachary Community School System does not knowingly discriminate against any employee or applicant for employment on the basis fo race, color, religion, gender, age, national origin, handicap, or status as a Vietnam era or disabled veteran. This policy encompasses recruitment, selection, assignment, promotion, transfer, termination, compensation, training and apprenticeship, and all other terms, conditions, benefits and privileges associated with employment. This policy extends to the educational programs and activities operated by the state, districts, and schools. Discrimination is specially prohibited by Title IX of the Education Amendments of 1972, as amended, and Title 45, Subtitle A, Part 66, of the implementing regulations administered by the Director of the Office of Civil Rights of the United States Department of Health, Education, and Welfare.
Section I Personal Information
Title Are you a citizen of the United States?
Yes No
First Name If you are not a US Citizen, do you have a legal right to work in this country?
Yes No

Middle Name

Current Phone
Last Name Alternate Phone
Social Security Number (no dashes please) Email Address
Permanent Mailing Address City State Zip
Have you ever worked in a school system?
Yes No		 Have you ever applied for a teaching position in this state?
Yes No
Have you ever applied for a non-teaching position in this school district?
Yes No		 Have you retired from a state retirement system?
Yes No
Are you currently certified for the position for which you are applying?
Certified Not Certified Not Certified, but have applied		 If yes, name the school system from which you retired
Date of Retirement
Section II Position Desired
Select Preferred Assignments from position list below (use Ctrl-key for multiple selections)
 If you also wish to be considered for a coaching assignment, list sports (with experiences and records in order of preference)
What student activities are you willing to sponsor? What proficency do you have in computer technology?
Section III Academic Record (beginning with the most recent)
Institution and Location
Dates of Attendance
DegreeDate
Major/Field of Study
Full/Part-time
GPA
From (MO/YR)
To (MO/YR)
Awarded/Expected
Section IV Student Teaching Experience (beginning with the most recent)
Dates
Name of School & School District
Grade and/or subject taught
Name, Address and Phone of Cooperating Teacher(s)
Name, Address and Phone of University Supervisor(s)
From (MO/YR)
To (MO/YR)
Section V Employment Information - Teaching Experience (beginning with the most recent)
Dates
School District
Grade and/or subject taught
Name, Address and Phone of School District
Reason for Leaving
From (MO/YR)
To (MO/YR)
Section VI Employment Information - Other Than Teaching (beginning with the most recent)
Dates
Position
Name, Address and Phone of Employer
Reason for Leaving
From (MO/YR)
To (MO/YR)
Section VII Certification Information
State Certificate
Type
Number Issue Date
Is your state certificate Current Expired?

Choose areas of certification: (use Ctrl-key for multiple selections)
Do you hold a valid certificate from another state?
 Yes No

Out of State Certificate
Type
Number Issue Date

List areas of certification (out of state)
Do you currently hold a National Board for Professional Teaching Standards Certification?
 Yes No
Section VIII PRAXIS/NTE?Scores
National Teacher Examination (NTE)
Have you taken the NTE?(required through 08/31/99)?
 Yes No If yes, when? ?
If yes, provide the following scores:
Professional Knowledge Score
General Knowledge Score
Communication Skills Score
Specialty Area Score		 PRAXIS Examination
Have you taken the PRAXIS?(required through 09/01/99)?
 Yes No If yes, when? ?If yes, provide the following scores:
If not, when do you plan to take it?
PPST(Written Test)
Reading Score
Writing Score
Mathematics Score

OR

Computer Based Test
Reading Score
Writing Score
Mathematics Score

Other Test(s)
Test Name
Test Code
Score

Test Name
Test Code
Score

Test Name
Test Code
Score

Section IX Professional References
A minimum of two (2) references must be submitted
Name and Positon
School District
Complete Mailing Address
Telephone Number
Section X Additional Information
1. Are you presently employed? Yes No
2. Are you related to an employee/board member of the Zachary Community School District? Yes No
3. Have you ever been convicted of a felony? Yes No
4. Have you ever been terminated or recommended for dismissal by your employer? Yes No
 IF YOU CHECKED YES FOR QUESTIONS 3 OR 4
Briefly explain and send a letter of explanation to the personnel department
Did you patricipate in the State Teacher Assistance and Assessment Program?(LATAAP) ? Yes No
When Where

Did you successfully complete the program? Yes No
Section X Additional Information
RELEASE OF ASSESSMENT AND EVALUATION INFORMATION
La.R.S. 17:3884(D) requires that any school board within to hire a person who has been assessed or evaluated pursuant to the Children First Act La.R.S. 17:3871, et seq., whether that person is already employed by that school system or not, shall request such person?s assessment and evaluation results as part of the application process. Please be advised that, as part of the mandated process, your previous assessment and evaluation results will be requested. You have the opportunity to apply, review the information received, and provide any response or information you deem appropriate.


MISCONDUCT DISCLOSURE
I authorize you to make investigations and inquiries of my personal, employment, and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, or persons from liability in responding to inquiries in connection with my application. School boards within the state reserve the right to reject an incomplete application and further reserve the right to dispose of any application which is not current in a one-year period. References and personal information which become a part of this record are to be regarded as confidential and shall not be revealed to me. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employing authority, if employed.

I certify that the answers given herein are true and complete to the best of my knowledge. I have read and agree with the information provided to me.


SEXUAL MISCONDUCT DISCLOSURE STATEMENT
Pursuant to La. R.S.? 17.81.9, I authorize the disclosure of information from any current or previous employer of mine, if such employer is/was a city, parish, or other local school board, relative to all instances of sexual misconduct with students committed by me, if any. I expressly give consent for the release of such information from any school employee and/or teacher personnel file maintained with respect to me. I release my current or previous employer, if employer is/was a city, parish, or other local school board, and any employee acting on behalf of such employer from any liability for providing any information relative to all instances of sexual misconduct with student(s) as defined by BESE committed by me, if any.


Sexual misconduct with student(s) is defined by BESE in Section 501 of Bulletin 741, Louisiana Handbook for School Administrators as:

1. Any conduct that would amount to sexual harassment under Title IX of the U.S. Education Amendments of 1972;
2. Any conduct that would amount to sexual abuse of a minor person under state criminal codes;
3. Any sexual relationship by a school employee with a student, regardless of the student?s age; with a former student under 18, with a former
students (regardless of age) who suffers from a disability that would prevent consent in a relationship. All students enrolled in the school and in
any organization in which the school employee holds a position of trust and responsibility are included; and
4. Any activity directed toward establishing a sexual relationship such as sending intimate letters; engaging in sexualized dialogue in person, via the Internet, in writing or by phone; making suggestive comments; dating a student.

I understand that if employed by Zachary Community School Board, any misrepresentation or omission of facts in my employment application may be cause for dismissal.

I authorize the Zachary Community School Board to request information from my current or previous employer relative to sexual misconduct with student(s) as defined by BESE, committed by me, if any. I further authorized the Zachary Community School Board to request information from my current or previous employer relative to sexual misconduct with student(s) as defined by BESE, committed by me, if any, which is contained in my personnel files.

I understand that any offer of employment is contingent upon satisfactory references from current or previous employers.

I Agree I Disagree