Mountain View-Birch Tree R-III School District

1) Name

Last, First, Middle

2) Social Security Number:

3) Email Address:

4) Phone Number:

5) Address:

City, State, Zip

6) Desired Position:

7) List of extra-curricular activities you are qualified to coach or sponsor:

8) Current Subject Area Teaching Certification in Missouri:

Subject, Grade Levels, Expiration Date

9) Name of school and location. Indicated high school, college, and or technical schools

Please put a number associated with each school so you can answer the follow up questions in a way that keeps the schools organized

10) Name of Diploma or Degree

If more than one please continue with the same number sequence as the previous question

11) Major subject area and number of credit hours

If more than one please continue with the same number sequence as the previous question

12) Minor subject area and number of credit hours

If more than one please continue with the same number sequence as the previous question

13) Grade Point Average (GPA)

If more than one please continue with the same number sequence as the previous question

14) Experience

Teacher/Work Experience, Date of Employment, Subject Area taught/Nature of Work

15) Total number of full years of certified teaching/administrative experience: _____ years

16) List persons qualified to provide information regarding your qualifications to be successful in the position you seek. For teachers, please include persons who have personal knowledge of your ability

(i.e. supervising teacher, principals, superintendent, etc.) Name of reference, Reference addresses, Email and Phone Number, Reference Vocational and Title, Reference Relation to your work

17) Are you presently under contract? _________Until when? _________

18) Why do you want to leave your current position/employment? (optional)

19) If you are not currently employed, why did you leave your last position?

20) Have you ever been asked to resign?

Yes

No

21) If yes, please please provided an explanation below (optional)

Where? Why?

22) Have you ever been non-renewed?

Yes

No

23) Have you ever resigned in lieu of being fired, dismissed, terminated or otherwise involuntarily discharged from your employment?

Yes

No

24) If yes, please please provided an explanation below (optional)

25) Have you ever entered into separation agreement or settlement in connection with either voluntary or involuntary termination of your employment?

Yes

No

26) If yes, please please provided an explanation below (optional)

27) Are you legally authorized to work in the United States?

Yes

No

28) If you answered "yes" to any of the questions on this page, please provide an explanation below. (optional)

Background Record

Prior to being considered for employment, all applicants must complete a criminal background check and pass

a drug test. Specific information regarding how to complete this process can be obtained from the central

office secretary.

29) Has the MDFS, the MCD, or similar agency in any other state ever issued a report, to any degree whatsoever, that you engaged in child abuse or neglect?

MDFS-Missouri Division of Family Services. MCD-Missouri Children's Division

Yes

No

30) Have you ever been arrested for, charged with, or convicted of a felony, misdemeanor, or ordinance violation? (exclude traffic offenses for which you were not sentenced to jail)

Yes

No

31) Have you ever received a suspended imposition of sentence or suspended execution of sentence for a felony, misdemeanor, or ordinance violation?

Exclude traffic offenses for which you were not sentenced to jail or for which the fine was less than $100.00. Do not exclude offenses related to driving while intoxicated or driving while intoxicated (DWI) or under the influence (DUI)

Yes

No

32) Have you ever been charged with or found guilty of driving while intoxicated (DWI) or driving while under the influence (DUI).

Yes

No

33) Are you currently on probation or parole?

Yes

No

34) If you answered “yes” to any of the questions above, please provide an explanation on a separate document and attach it to this application.

Max 10 files | 200 MB limit

35) Has the MDFS, the MCD, or similar agency in any other state ever issued a report, to any degree whatsoever, that you engaged in child abuse or neglect?

MDFS-Missouri Division of Family Services. MCD-Missouri Children's Division

Yes

No

36) Have you ever been arrested for, charged with, or convicted of a felony, misdemeanor, or ordinance violation? (exclude traffic offenses for which you were not sentenced to jail)

Yes

No

37) Have you ever received a suspended imposition of sentence or suspended execution of sentence for a felony, misdemeanor, or ordinance violation?

Exclude traffic offenses for which you were not sentenced to jail or for which the fine was less than $100.00. Do not exclude offenses related to driving while intoxicated or driving while intoxicated (DWI) or under the influence (DUI)

Yes

No

38) Have you ever been charged with or found guilty of driving while intoxicated (DWI) or driving while under the influence (DUI).

Yes

No

39) Are you currently on probation or parole?

Yes

No

40) If you answered “yes” to any of the questions above, please provide an explanation on a separate document and attach it to this application.

Max 10 files | 200 MB limit

Records Check, Falsification, and Information Release Waiver

I hereby authorize the Mountain View-Birch Tree R-III School District to contact all persons and entities listed

on this application and to make all other contacts, inquiries and investigations that the District deems necessary

to verify my education, employment and criminal/child abuse history, including but not limited to contacting

current and/or past employers, educational institutions, law enforcement, and child abuse agencies. I hereby

consent to the release of any such information by third persons.

I hereby release the directors, officers, employees and agents of both the Mountain View-Birch Tree R-III School

District and each of my past employers from appraisals of my past performance made to the Mountain View-

Birch Tree R-III School District.

I understand that employment with the Mountain View-Birch Tree R-III School District is contingent upon the

satisfactory completion of a criminal and child abuse/neglect record and background check 7KLV includes a

complete fingerprint criminal record check.

I hereby certify that all information provided by me in connection with this application is true, accurate and

complete. I understand that any false, inaccurate, incomplete, omitted, or misleading information provided on

this application, or on any documents submitted in connection with this application, shall be cause for refusal to

hire, or if the applicant has been hired, for immediate termination.

I agree that a reference can be submitted for me as a current or former employee of the MVBT R-III School District by the Superintendent or designee should it be necessary.

41) Applicant Signature

Your signature indicates acknowledgement of the information above.

Signature

I understand that my typed signature is the legal equivalent of my handwritten signature on this document.

Mountain View-Birch Tree R-III School District

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