HENRYETTA PUBLIC SCHOOLS 1801 W TROY AIKMAN DR HENRYETTA OK 74437 PH 918.652.6523 AN EQUAL OPPORTUNITY EMPLOYER CERTIFIED STAFF GENERAL INFORMATION (PLEASE PRINT) DATE NAME FIRST NAME MIDDLE NAME LAST NAME OTHER NAME(S) PRESENT ADDRESS # CELL # SOCIAL SECURITY NUMBER EMAIL ADDRESS PERSONAL HOMEPAGE? YES OR NO GENERAL QUESTIONS WHAT POSITION ARE YOU APPLYING FOR? ARE YOU CURRENTLY UNDER CONTRACT? YES OR NO IF SO, WHERE DO YOU POSSESS A VALID OKLAHOMA TEACHING LICENSE/CERTIFICATE? YES OR NO IF NO, HAVE YOU APPLIED? YES OR NO DO YOU HOLD OR HAVE YOU EVER HELD A TEACHING CERTIFICATE/LICENSE IN ANOTHER STATE? IF SO, PLEASE LIST THE STATE AND CERTIFICATE/LICENSE NUMBER. WHEN ARE YOU AVAILABLE TO START WORK? HAVE YOU BEEN PREVIOUSLY EMPLOYED BY HENRYETTA PUBLIC SCHOOLS? YES OR NO IF YES, IN WHAT CAPACITY 1
IS THERE ANY REASON, PAST OR PRESENT THAT YOU SHOULD NOT BE CONSIDERED FOR A CERTIFIED POSITION AT HENRYETTA PUBLIC SCHOOLS? HOW DID YOU HEAR ABOUT EMPLOYMENT OPPORTUNITIES WITH THIS DISTRICT? _ ARE YOU A RETIRED TEACHER CURRENTLY RECEIVING A PENSION FROM OKLAHOMA TEACHER S RETIREMENT SYSTEM? YES OR NO IF YES, HOW LONG HAVE YOU BEEN RETIRED? EDUCATIONAL BACKGROUND HIGH SCHOOL ATTENDED COLLEGE OR UNIVERSITY ATTENDED DATE ATTENDED TO/FROM DEGREE RECEIVED DATE OF DEGREE EMPLOYMENT HISTORY THE DISTRICT WILL CONDUCT A BACKGROUND CHECK TO VERIFY INFORMATION PROVIDED. CONSENT AND RELEASE OF ALL CLAIMS AGAINST PREVIOUS EMPLOYERS: SIGN BELOW IF YOU AGREE THAT THE DISTRICT MAY CONTACT YOUR PREVIOUS EMPLOYERS AND ASK THEM MORE DETAILED QUESTIONS ABOUT YOUR WORK EXPERIENCE, IF YOU SPECIFICALLY CONSENT TO THE RELEASE OF INFORMATION BY THESE PRIOR EMPLOYERS BY THE DISTRICT, AND AGREE TO RELEASE SUCH PRIOR EMPLOYERS, THEIR EMPLOYEES, AND THEIR GOVERNING BOARDS, FROM ANY AND ALL CAUSES OF ACTION OR OTHER POTENTIAL CLAIMS WHICH YOU COULD HAVE AGAINST THEM FOR ANSWERING QUESTIONS ABOUT YOUR WORK EXPERIENCE. THIS CONSENT IS A CONVENANT NOT TO SUE ANY PRIOR EMPLOYER, THEIR EMPLOYEES, OR THEIR BOARD MEMBERS FOR DEFAMATION, REGARDLESS OF WHAT SAID PRIOR EMPLOYERS MAY RELATE TO THE DISTRICT REGARDING YOUR PREVIOUS EMPLOYMENT EXPERIENCE. I HAVE READ THIS CONSENT AND RELEASE OF ALL CLAIMS, AND IN CONSIDERATION OF BEING CONSIDERED AN APPLICANT FOR EMPLOYMENT AGREE TO ITS TERMS. APPLICANT SIGNATURE 2
TEACHING EXPERIENCE SCHOOL NAME AND DISTRICT GRADES AND SUBJECTS DATES FROM/TO MILITARY EXPERIENCE? YES OR NO IF YES, SUPPLY DD214 (REPORT OF SEPARATION) PROFESSIONAL REFERENCES LIST ONLY THOSE PERSONS WHO ARE QUALIFIED TO EVALUATE YOUR QUALIFICATIONS FOR POSITIONS SOUGHT, INCLUDE PRINCIPALS/SUPERINTENDENTS OF SYSTEMS WHERE EXPERIENCE WAS GAINED. COOPERATING TEACHER NAME TITLE COLLEGE, SCHOOL AND COLLEGE SUPERVISOR TITLE COLLEGE, SCHOOL AND COLLEGE ADVISOR TITLE COLLEGE, SCHOOL AND COLLEGE PLACEMENT OFFICER TITLE COLLEGE, SCHOOL AND OTHER TITLE COLLEGE, SCHOOL AND OTHER TITLE COLLEGE, SCHOOL AND 3
PLEASE USE THIS SPACE TO EXPRESS YOUR BASIC VIEWS IN RESPONSE TO THE FOLLOWING QUESTIONS. THEY SHOULD BE WELL THOUGHT OUT SINCE YOUR VIEWS ARE VERY IMPORTANT TO US. 1. WHAT IS IT THAT GIVES YOUR PROFESSIONAL LIFE AS A TEACHER MEANING? 2. WHAT DO YOU CONSIDER TO BE YOUR MAJOR STRENGTHS IN WORKING WITH STUDENTS? 3. HOW DO YOU DETERMINE WHAT TO TEACH YOUR STUDENTS? 4. IN WHAT AREAS DO YOU BELIEVE YOUR STUDENTS WILL GROW THE MOST BY HAVING YOU AS THEIR TEACHER? RELATED EXPERIENCE LIST ANY SPECIAL ABILITIES INCLUDING BILINGUAL ABILITIES, INTERESTS, COMMUNITY ACTIVITIES, HIGH SCHOOL, OR COLLEGE ACTIVITIES WHICH WOULD ENHANCE YOUR OPPORTUNITY FOR EMPLOYMENT, INCLUDING UNIQUE OR SPECIAL ACHEIVEMENTS. LIST ANY PROFESSIONAL ACTIVITIES, INCLUDING PROFESSIONAL OR HONORARY ORGANIZATIONS, RESEARCH STUDIES, PUBLICATIONS AND/OR PRESENTATIONS. 4
BACKGROUND INFORMATION 1. DO YOU HAVE A RELATIVE WHO WORKS FOR HENRYETTA PUBLIC SCHOOLS (HPS), OR WHO SERVES AS A MEMBER OF THE BOARD OF EDUCATION? YES OR NO IF YES, LIST THEIR NAME AND RELATIONSHIP TO YOU. 2. FEDERAL IMMIGRATION LAWS REQUIRE EMPLOYERS TO VERIFY AND ATTEST TO THE EMPLOYMENT ELIGIBILIY OF ALL NEW EMPLOYEES. IF EMPLOYED, CAN YOU FURNISH CURRENT VERIFICATION OF YOUR LEGAL RIGHT TO WORK IN THE UNITED STATES? YES OR NO IF NO, HAVE YOU INITIATED THE PROCESS BY WHICH YOU WILL GET WORK AUTHORIZATION? YES OR NO 3. ARE YOU PRESENTLY BEING INVESTIGATED OR UNDER A PROCEDURE TO CONSIDER YOUR DISCHARGE FOR MISCONDUCT BY YOUR PRESENT EMPLOYER OR HAVE YOU OFFERED A RESIGNATION TO YOUR CURRENT OR ANY PREVIOUS EMPLOYER TO AVOID AN INVESTIGATION FOR ANY ALLEGED MISCONDUCT? YES OR NO IF YES, DETAILS 4. HAVE YOU EVER BEEN REPRIMANDED, DISCIPLINED, DISCHARGED, OR ASKED TO RESIGN FROM A PRIOR POSITION? YES OR NO IF YES, DETAILS 5. HAVE YOU EVER RESIGNED FROM A PRIOR POSITION WITHOUT BEING ASKED, BUT UNDER CIRCUMSTANCES INVOLVING YOUR EMLOYER S INVESTIGATION OF YOUR SEXUAL CONTACT WITH ANOTHER PERSON, OF MISHANDLING FUNDS OR OF CRIMINAL CONDUCT RESULTING IN A CONVICTION OR CRIMINAL PENALTY? YES OR NO IF YES, DETAILS 6. HAVE YOU EVER BEEN NAMED BY A STATE AGENCY RESPONSIBLE FOR CHILD WELFARE AS A PERPETRATOR IN AN INDICATED REPORT OF CHILD ABUSE OR NEGLECT IF SUCH REPORT WAS NOT REVERSED AFTER EXHAUSTION OF ANY APPEAL? YES OR NO IF YES, DETAILS 5
7. EXCEPT FOR MINOR TRAFFIC VIOLATIONS SUCH AS PARKING OR SPEEDING, HAVE YOU EVER BEEN CONVICTED, FINED, PLACED ON PROBATION, GIVEN A SUSPENDED SENTENCE, GIVEN DEFERRED ADJUDICATION, ENTERED A PLEA OF GUILTY OR NO CONTEST (NOLO CONTENDERE), OR FORFEITED BAIL IN CONNECTION WITH ANY VIOLATION OF LAW (MISDEMEANOR OR FELONY), REGARDLESS OF ANY SUBSEQUENT COURT DISMISSAL, SEALING OR EXPUNGEMENT? YES OR NO IF YES, DETAILS _ 8. HAVE YOU EVER HAD A CERTIFICATE, CREDITIAL, LICENSE OR OTHER DOCUMENT AUTHORIZING PUBLIC SCHOOL SERVICE OR TEACHING SUSPENDED, REVOKED, LIMITED, VOIDED, DENIED OR OTHERWISE REJECTED IN OKLAHOMA OR ANY OTHER STATE OR PLACE? YES OR NO IF YES, DETAILS. 9. ARE YOU NOW THE SUBJECT OF ANY INQUIRY, DISCIPLINARY ACTION, REVIEW OR INVESTIGATION, IN ANY DISTRICT, BY A TEACHER LICENSING AGENCY, OR IN THE COURTS OF OKLAHOMA OR ANY STATE IN CONNECTION WITH ANY ALLEGED MISCONDUCT? YES OR NO IF YES, DETAILS 10. ARE YOU ABLE TO PERFORM THE ESSENTAIL JOB FUNCTIONS OF THE JOB YOU ARE SEEKING, INCLUDING TIME AND ATTENDANCE REQUIREMENTS, WITH OR WITHOUT REASONABLE ACCOMODATIONS? YES OR NO IF NO, DETAILS 11. HAVE YOU: BEEN REQUIRED TO REGISTER AS A SEX OFFENDER UNDER THE OKLAHOMA SEX OFFENDER REGISTRATION ACT, THE MARY RIPPY VIOLENT CRIME REGISTRATION ACT OR SIMILAR LAWS IN ANOTHER STATE? YES OR NO IF YES, DETAILS ENTERED A PLEA OF GUILTY OR NOLO CONDENERE OF A STATE (ANY STATE) OR FEDERAL FELONY CHARGE? (THIS INCLUDES CRIMINAL CASES INVOLVING A DEFERRED SENTENCE, DEFERRED JUDGEMENT AND ANY EXPUNGE OF THE RECORDS ) YES OR NO IF YES, DETAILS 6
BEEN CONVICTED OF A STATE (ANY STATE) OR FEDERAL FELONY OFFENSE? YES OR NO IF YES, DETAILS BEEN CHARGED WITH A STATE (ANY STATE) OR FEDERAL FELONY OFFENSE WHICH WAS REDUCED TO A MISDEMEANOR OFFENSE TO WHICH YOU ENTERED A PLEA OF GUILTY OR NOLO CONTENDERE? (THIS INCLUDES CRIMINAL CASES INVOLVING A DEFERRED SENTENCE, DEFERRED JUDGEMENT OR ANY EXPUNGE OF THE RECORDS ) YES OR NO IF YES, DETAILS ENTERED A PLEA OF GUILTY OR NOLO CONTENDERE TO OR BEEN CONVICTED OF A STATE (ANY STATE) OR FEDERAL MISDEMEANOR CHARGE INVOLVING ILLEGAL CHEMICAL SUBSTANCES OR ILLEGAL SEXUAL ACTIVITY? (THIS INCLUDES CRIMINAL CASES INVOLVING A DEFERRED SENTENCE, DEFERRED JUDGEMENT AND ANY EXPUNGE OF THE RECORDS ) YES OR NO IF YES, DETAILS ENTERED INTO A DEFERRED PROSECUTION AGREEMENT WITH A STATE (ANY STATE) OF FEDERAL PROSECUTOR? YES OR NO IF YES, DETAILS *APPLICANT UNDERSTANDS THAT PROVIDING A FALSE RESPONSE TO ONE OR MORE OF THE ABOVE QUESTIONS WILL CAUSE DENIAL OF EMPLOYMENT OR MAY CAUSE DISMISSAL FROM EMPLOYMENT IF THE FALSE RESPONSE IS LEARNED OF AFTER EMPLOYMENT BEGINS. YES OR NO VOLUNTARY EEO VOLUNTARY EQUAL EMPLOYMENT OPPORTUNITY (EEO) I CHOOSE TO FILL OUT THIS SECTION? YES OR NO GENDER: MALE OR FEMALE RACE AND ETHNICITY: HISPANIC OR LATINO 7
REFERENCES NAME STREET ADDRESS TITLE/POSITION NUMBER EMAIL ADDRESS NAME STREET ADDRESS TITLE/POSITION NUMBER EMAIL ADDRESS 1. TRANSCRIPT OF COLLEGE CREDITS 2. COPY OF OKLAHOMA TEACHING CERTIFICATE 3. RESUME ENCLOSURE DOCUMENTS 8
APPLICANT S PERSONAL CERTIFICATION AND AUTHORIZATION TO ACCESS PERSONAL DATA I HEREBY CERTIFY THAT THE ABOVE INFORMATION, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND COMPLETE. ANY MISREPRESENTATION OR WILLFUL OMISSIONS OF FACTS SHALL BE SUFFICIENT CAUSE FOR DISQUALIFICATION OF THIS APPLICATION OR TERMINATION OF EMPLOYMENT. FURTHERMORE, IT IS UNDERSTOOD THAT THIS APPLICATION AND RECORDS BECOME THE PROPERTY OF THE DISTRICT, WHICH RESERVES THE RIGHT TO ACCEPT OR REJECT IT. I FURTHER AGREE TO ALL RULES, REGULATIONS AND POLICIES OF THE DISTRICT. I UNDERSTAND THAT THE APPLICATION WILL REMAIN ACTIVE FOR ONE YEAR AFTER ITS COMPLETION, AND THAT I MUST NOTIFY THE DISTRICT IF I WISH TO BE CONSIDERED BEYOND THAT PERIOD. ALL PERSONS, FIRMS AND ENTITIES LISTED IN THIS APPLICATION ARE HEREBY AUTHORIZED TO RELEASE ANY INFORMATION OR RECORDS CONCERNING ME TO THE DISTRICT, AND ARE RELEASED BY ME FROM ANY LIABILITY AS A RESULT OF FURNISHING RECORDS AND INFORMATION. SIGNATURE OF APPLICANT DATE *PLEASE NOTE: IT IS OUR POLICY TO INTERVIEW APPLICANTS ONLY WHEN THERE ARE SPECIFIC VACANCIES TO FILL. APPLICATIONS NEED TO BE UPDATED EACH YEAR IN ORDER TO BE KEPT ACTIVE. 9