Professional Staff Application

(An Equal Opportunity Employer)

Date

Name

Address

Mailing Address (if different than above)

Telephone Number

Email Address

Position(s) Desired

Course(s) Qualified to Teach

Are you certified or licensed in any other skill(s) or profession(s)? Yes No

If yes, provide skill(s) and/or profession(s)

__________________________________________________________________________________________________________________________________________________________________________

Have you taken the MTTC test(s)? (required) Yes No

If yes, in which area(s) did you receive a passing score?

If no, what date do you expect to take the test?

__________________________________________________________________________________________________________________________________________________________________________

Are you currently employed? (required) Yes No

Present or Last Salary

Name and Address of present or most recent employer

May we contact present employer? (required) Yes No

If no, please provide explanation

If currently teaching, are you under contract? Yes No

If yes, when does your current contract expire?

When would you be available for a personal interview?

__________________________________________________________________________________________________________________________________________________________________________

Education and Professional Training

List High School, Colleges and Universities Attended

High School, Location, Degree, Major, Minor

College / University, Location, Degree, Major, Minor

__________________________________________________________________________________________________________________________________________________________________________

Are you presently working toward a higher degree? Yes No

If yes, expected completion date

Degree

Name under which credentials are filed

Name of College / University placement agency that has your most complete record on file

__________________________________________________________________________________________________________________________________________________________________________

Teaching Experience

Name of Institution, Subject(s) taught, Dates, Highest salary received, Name of supervisor, Reason for leaving

__________________________________________________________________________________________________________________________________________________________________________

Certification

Type of Certification, State, Date issued, Expiration date, Name under which the certificate was granted

Type of Certification, State, Date Issued, Expiration date, Name under which the certificate was granted

__________________________________________________________________________________________________________________________________________________________________________

Work Experience other than Teaching

Name of Company, Address, Type of work, Employment dates, Reason for leaving

__________________________________________________________________________________________________________________________________________________________________________

References: Character

Name, Position, Address and Telephone number

__________________________________________________________________________________________________________________________________________________________________________

References: Professional

Name, Position, Address and Telephone number

Name, Position and Telephone number

__________________________________________________________________________________________________________________________________________________________________________

Have you been granted tenure in Michigan? Yes No

If yes, provide name of district employed at time of receiving tenure

Have you ever been denied tenure or had a teaching contract non-renewed? Yes No

If yes, in which district?

__________________________________________________________________________________________________________________________________________________________________________

College Extracurricular Activities

List any extracurricular activities in which you participated while in college (i.e., student government, forensic, publication honorary, athletic, or fraternal):

Hobbies and Special Interests

List any hobbies or special recreational interests you have (i.e., collecting, sports, music, traveling, etc.):

Experience Working with Students

List experiences you have had working with young people (other than teaching) (i.e., scout work, summer camps, church activities, etc.)

__________________________________________________________________________________________________________________________________________________________________________

Have you ever been convicted of a felony or misdemeanor, including traffic violation? Failure to disclose accurate information may result in immediate termination of employment. (required) Yes No

If yes, provide details

__________________________________________________________________________________________________________________________________________________________________________

Affidavit:

I hereby certify all statements in this application to be true and authorize Jackson Preparatory & Early College authorities to verify same, and to obtain and check references by contacting, either verbally or in writing, any former employer, any university or college attended, and any listed references. I further understand and agree that the acceptance of this application by Jackson Preparatory & Early College does not impose any obligation for placement upon the district.

Electronic Signature (full name)

Date

It is the policy of Jackson Preparatory & Early College not to discriminate on the basis of race, color, religion, national origin or ancestry, age, sex, marital status or handicap in its education programs, activities or employment as required by Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title IX of the Educational Amendment of 1972, or American Disabilities Act of 1990. Direct all inquiries to the Administration Office, 2111 Emmons Road, Jackson, Michigan. Telephone: (517) 768.7093.

Your application will be kept on file for at least (3) months. It is your responsibility to provide transcripts of college credits, evidence of certification, and confirmation of the MTTC tests (if requested) that you have passed as required by position for which you have applied.