AN EQUAL OPPORTUNITY EMPLOYER

PERSONAL DATA

Name ___________________________________ SS# ________________________

            (include maiden name if applicable)     

Phone #(s) _______________________________ Date of Birth __________________

                               (include area code)

Address _____________________________________________________________

                Street / PO                                City/State                                            Zip                   

Do you have any conditions that interfere with job performance? _____________________

If "yes" explain: __________________________________________________________

EDUCATIONAL AND TEACHER TRAINING

College or University Attended

_______________________________________________________________________

Name                                            Address                                    Dates attended            Degree Earned

_______________________________________________________________________

Name                                            Address                                    Dates attended            Degree Earned

TN Teaching Certificate Number: __________________________ Exp. Date ____________

If not received, date applied for: ________________________________________________

Areas of Endorsement _____________________________ Certificate Type _____________

         No application will be considered without a copy of a current Tennessee Certificate.

TEACHING EXPERIENCE

List teaching experience beginning with the most recent:

School _________________________________ Address _________________________

            Grade or Subject Taught ____________________________  No. Years __________

School _________________________________ Address _________________________

            Grade or Subject Taught _____________________________  No. Years _________

Other non-teaching experience _________________________________________________

_________________________________________________________________________

_________________________________________________________________________

REFERENCES

If you have not had teaching experiences, please list your supervising teacher during student

teaching. Also give one person from your teacher training program. The third reference may

be of your own choosing. If you have had any teaching experience, the first two references

should be your last principal, and either the personal director, superintendent, or supervisor

of instruction in the LAST school system in which you taught.

              Name                                                    Title                                                Phone

1. __________________________________________________________________________

Address _____________________________________________________________________

2. ___________________________________________________________________________

Address ______________________________________________________________________

3. ___________________________________________________________________________

Address ______________________________________________________________________

Please answer the following by circling the correct answer:

1. Have you ever been convicted of a felony or misdemeanor in any state in the United States?

                YES -- if yes, explain fully on a separate sheet                                NO

2. Have you ever been dismissed from any previous employment for improper or unprofessional

conduct, inefficient service, neglect of duty, incompetence, or insubordination.

                YES -- if yes, explain fully on a separate sheet                                NO

I hereby certify that the above answers are true to the best of my knowledge. I also understand

upon employment, I must submit to the Board of Education, the attached physical form at my

own expense.

_________________________________                    ____________________________

Date                                                                                        Signature of Applicant

COPY OF CERTIFICATE ATTACHED:

___________                        _______________

Yes                                            Applied

It is the policy of the Smith County School System not to discriminate on the basis of sex, race,

national origin, creed, age, martial status, or disability in its educational programs, activities

or employment policies as required by TITLE VI and VII of the 1964 civil rights Act, Title IX of

the 1972 Educational Amendments and section 504 of the Federal Rehabilitation Act of 1973.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Procedure for Reimbursement of Background Check Cost

1.    Certified Personnel - Fulltime

1. May be employed pending a positive background check.

2. The employee shall pay the cost of the background check. If the background check is positive, the employee will be reimbursed. If the background check is negative, the employee will be terminated and the cost of the background check will not be refunded.

2.    Non-Certified Employees - Fulltime

A fulltime employee shall be required to pay the cost of the background check. Said employee will be reimbursed the cost of a positive background check. A negative background check shall result in dismissal and the cost of the background check will not be refunded.

 

3.    Part-Time Employees (except Bus Drivers)

Employees shall pay the cost of a background check. After working three (3) complete days, the employee will be reimbursed the cost of a positive background check. Said employee who has a negative background check shall be terminated, and the cost of the background check will not be refunded.

 

4.    Bus Drivers - Full and Part Time

Employees shall pay for the cost of the background check. If the employee receives a positive background check, said employee will be reimbursed for the cost of the background check after successfully completing driving one time. Employees not receiving a positive background check shall be terminated, and the cost of the background check will not be refunded.

 

To process your background check the Tennessee Bureau of Investigations requires a $60.00 money order or cashiers check payable to the Tennessee Bureau of Investigations.

"I understand the background investigation requirements and the conditions for reimbursement for the cost of the background investigation."

____________________________________________

                    Signature Required