First Name
Middle Initial
Last Name
Social Security Number
Street Address
City
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Zip Code
Home Phone Number
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Previous Name(s)

Position Information

Specific Position for which you are applying:

Other Positions in which you are interested or for which you qualify:

Coaching/Advising Interests and Experience:

Do you hold a valid Montana Certificate?      Yes No     Folio #:
    Class:     Level:

Grades covered by your certificate: K-8     5-12     7-12     K-12
Expiration date:  Format: mm/dd/yyyy

(If applicable):
Major area of Preparation/endorsements:
Minor area of Preparation/Endorsements:

(Special Ed): Do you hold a Montana License?     Yes No     License Number:
Expiration Date:  Format: mm/dd/yyyy

Please answer the following questions:

Do you have the legal right to work in the United States?  Yes No

Are you able with or without reasonable accommodation to perform the functions of the job for which you are applying?  Yes No

Have you ever been released or discharged from employment or resigned to avoid such release or discharge?  Yes No
If yes, please explain, include date of discharge or resignation and reason for discharge or resignation:

I hereby certify that (check the applicable box and provide the information requested):
 I have not pleaded guilty to or have been convicted of any violation of criminal law, including criminal convictions resulting from a deferred sentence or a plea of nolo contendere/no contest (minor traffic offenses excepted).
 I have pleaded guilty to or have been convicted of at least one violation of criminal law. Please attach and sign a complete description of the circumstances surrounding such conviction. (This may not necessarily disqualify a person from consideration for employment).

Additional Pertinent Information, Qualifications, Certificates:

REFERENCES
Please list current information for at least three and no more than five references below

Name	Title	Address	Phone (home and work)
1.
2.
3.
4.
5.

EDUCATION HISTORY

University/College	Location	Subject	Degree	Year	GPA
1.
2.
3.
4.
5.
6.

Credits completed beyond attainment of teaching certification (note whether semester or quarter credits):
Undergraduate
Graduate          

EMPLOYMENT RECORD List your present or most recent employer. Describe your employment history, accounting for all time during at least the last 15 years. You may include volunteer and paid experience. DO NOT substitute a resume. You may attach additional information.

Do you wish to be notified before we contact your current or previous employers? Yes No

Employer: Your Job Title:
Address:
Immediate supervisor and title:
Telephone: Employment dates: From To

Job Duties (brief statement - be sure to list all duties related to this position):

Reason(s) For Leaving:
Salary:

Employer: Your Job Title:
Address:
Immediate supervisor and title:
Telephone: Employment dates: From To

Job Duties (brief statement - be sure to list all duties related to this position):
Reason(s) For Leaving:
Salary:

Employer: Your Job Title:
Address:
Immediate supervisor and title:
Telephone: Employment dates: From To

Job Duties (brief statement - be sure to list all duties related to this position):
Reason(s) For Leaving:
Salary:

Employer: Your Job Title:
Address:
Immediate supervisor and title:
Telephone: Employment dates: From To

Job Duties (brief statement - be sure to list all duties related to this position):
Reason(s) For Leaving:
Salary:

Employer: Your Job Title:
Address:
Immediate supervisor and title:
Telephone: Employment dates: From To

Job Duties (brief statement - be sure to list all duties related to this position):
Reason(s) For Leaving:
Salary:

Employer: Your Job Title:
Address:
Immediate supervisor and title:
Telephone: Employment dates: From To

Job Duties (brief statement - be sure to list all duties related to this position):
Reason(s) For Leaving:
Salary:

Employer: Your Job Title:
Address:
Immediate supervisor and title:
Telephone: Employment dates: From To

Job Duties (brief statement - be sure to list all duties related to this position):
Reason(s) For Leaving:
Salary:

Each participating school district prohibits discrimination against or harassment of any person employed by or seeking employment with the school district because of race, creed, religion, color, political affiliation or national origin or because of age, physical or mental disability, marital status, or gender when the reasonable demands of the position do not require an age, physical or mental disability, marital status, or gender distinction. People of disability may request reasonable accommodation in the hiring process by contacting the school district personnel office.

Any applicant chosen for employment must be able to produce a social security card, driver's license, or some other acceptable form of verification of employment eligibility in the United States pursuant to Form I-9 of the U.S. Department of Justice.

Similarly, a selected applicant must provide verification of having received a tuberculin (TB) test within the past year. Verification must include the date of the test, the results of the test, and the signature of the person who conducted the test. It is policy to require verification of a TB test from any candidate chosen for employment and to require submitted documentation of the results of a tuberculin (TB) test within seven (7) days of employment.

If employed by a participating school district, the applicant authorizes the school district to supply his/her employment record at the school district's sole discretion, in whole or part, to any prospective employer, government agency, or other party, when the school district's interest is deemed appropriate.

Each of the participating school districts are drug free, tobacco free schools and, as such, require all employees to adhere to specific drug free, tobacco free policies.

I understand that no offer of benefits, such as, but not limited to, a pension plan, insurance, vacation, or salary rate, is final until it has been reviewed by the Personnel/Human Resources Department, and fully approved by the (superintendent/board) or designated authorized representative. Further, I have read and understand the above policies of employment.

(On the printable form, there will be a line provided here for the candidate's signature and the date.)

Providing this information is strictly on a voluntary basis. State law requires that employers keep records on the race and sex of applicants and employees to facilitate the enforcement of equal employment opportunity laws. This statement will be filed separately from all of your other employment records. As required by state law, it will be available only to the school district personnel department and federal/state employment enforcement officers.

Complete the following information and return it with your completed application to the applicable school district office/s.

Date:

Sex: Female Male

Age:

Position applied for:

Check one of the following:

ALASKA NATIVE - A person having origins in any of the original peoples of North America and who maintains cultural identification through tribal affiliation or community recognition.

AMERICAN INDIAN - A person having origins in any of the original peoples of North America and who maintains cultural identification through tribal affiliation or community recognition.

ASIAN AMERICAN - A person having origins in any of the original people of the Indian Subcontinent, the Pacific Islands, or the Far East: For example, China, Japan, Korea.

BLACK - (not of Hispanic origin) - A person having origins in any of the black racial groups of Africa.

FILIPINO - A person having origins in any of the original peoples of the Philippine Islands.

SPANISH AMERICAN - A person of Mexican, Puerto Rican, Cuban, Central or South America or any other Spanish culture or origin regardless of race.

WHITE - (not of Hispanic origin) - A person having origins in any of the original peoples of Europe, North America, or the Middle East.

OTHER - Please specify: