Short Form Application for Certificated Positions
	Name: Telephone Contact: Email: Position Applied For: Date:
	Certification:   State:   HQ Content Area:
	Education and Employment history: Please check here if included in resume'.
	University/Degree:   Major:   Minor: University/Degree:   Major:   Minor:
	Please check here if you completed your student teaching or internship.
	Employer:   Dates:   Position: Employer:   Dates:   Position: Employer:   Dates:   Position:
	References: Please check here if included in resume’.
	List 3 professional references (2 must have observed you in a classroom setting)
	Name of Reference Email Address Phone Contact 1.     2.     3.
	*How did you hear about employment with LKSD?
	PROFESSIONAL HISTORY Have you obtained tenure status in any other School District? Yes No If yes, where?   When?   *Have you ever been denied tenure? Yes No If yes, explain:   *Have you ever had a teaching certificate or teaching license revoked or suspended? Yes No If yes, explain:   *Have you ever failed to be rehired, been asked to resign a position, resigned to avoid termination or been terminated from employment? Yes No
	*Can you perform all the essential job function(s) of the position(s) for which you are applying, with or without reasonable accommodation? Yes No

	List any accommodations:
	LEGAL INFORMATION/DISCLOSURES     Please note: Applicants are not obligated to disclose sealed or expunged records of convictions or arrest. Are you eligible to work in the United States? Yes No
	*Have you ever been arrested, charged, or convicted of a criminal offense other than a minor traffic violation? Yes No If yes, explain, giving dates:
	*Does your name appear on any Sex Offender Database in any state or country? Yes No
	*Have you ever had any indicated finding of child abuse filed in your name? Yes No If yes, explain, giving dates:
	Contract Status     *Are you currently under contract? Yes No If Yes, which district?   If Yes, when does your contract expire? When may your present employer be contracted?
	EQUAL OPPORTUNITY EMPLOYER
	The Lower Kuskokwim School District is an Equal Opportunity Employer who ensures equal employment opportunities regardless of race, creed, gender, color national origin, religion, age, sexual orientation, or disability. We have a policy of active recruitment of qualified minority teachers and non-certified employees.
	APPLICANT’S ACKNOWLEDGEMENT AGREEMENT:
	By checking the box below, candidate authorizes the school district to conduct an investigation of candidate pursuant to The School Code to determine whether candidate has been convicted of any criminal or drug offenses as set forth in such statute, and, upon request, agrees to execute an investigation authorization form as a condition for candidate’s employment.
	The School Code also stipulates that the School District perform a check on the Statewide Sex Offender Database. Candidate may not be employed unless such investigations have been initiated.
	I certify that the information given by me in this application is true in all respects, and I agree that if the Information given is found to be false in any way, it shall be considered sufficient cause for denial of employment or discharge. I authorize the use of any information in the application to verify my statement, and I authorize the use of any information in the application to verify my statement, and I authorize past employers, all references, and any other person to answer all questions asked concerning my ability, character, reputation, and previous employment record. I release all such persons from any liability or damage on account of having furnished such information.
	I,   Agree to all the terms above.   I Agree
	Please Note:
	A conviction will not necessarily bar you from employment. Facts, such as date of occurrence and rehabilitation will be considered. This information will be used only for jobrelated purposes and only to the extent permitted by applicable law.