ULYSSES USD #214 APPLICATION FOR CERTIFIED PERSONNEL
Please complete this application, print it, and mail to: USD #214, Attn: Bill Roberts, 111 S. Baughman, Ulysses, KS 67880
Date of Application:
Name:
E-Mail:
Social Security Number:
Telephone:
Present Address:
Permanent Address:
Position You Are Applying For:
Professional Data:
 BA/BS

MA/MS/MEd

Ed.S./Ph.D

ESL Endorsement? Yes No

Bilingual Endorsement? Yes No

Have you met Kansas Precertification testing requirements? Yes No

Number years of teaching experience

If Elementary, number of hours in reading

Date Available for Enployment

Sport or Student Activity you would feel qualified to coach or sponsor

List any Full Time Teaching /Clinical/Internship Experience you have had
Personal Data:
Condition of your health for the past three years

Number of days you have missed work in the last three years because of illness

Have you ever been convicted of a felony? No Yes

If yes, explain
Professional References:

A physical examination will be required before employment.

A Kansas Teaching Certificate must be on file before employment.

I certify the above information to be true, and understand that falsification could be grounds for termination.
Yes No

I expressly authorize the release to the educational agency receiving this application any records of information which may refer or relate to this application for employment, including, but not limited to, records of education instititutions, law enforcemetn or criminal justice agencies, agencies maintaining child abuse records, and previous employers. I hereby release and discharge the educational agency receiving this application and any responsible person(s) employed by the agency from any and all claims and liability which I may have or ever claim to have relating to information provided to the educational agency as part of this application for employment. Yes No

Date _________________

Name________________________________

Signature_____________________________