HERTFORD COUNTY PUBLIC SCHOOLS

P.O. Box 158 - 701 N. Martin Street

Winton, North Carolina 27986
(252) 358-1761
www.hertford.k12.nc.us
CERTIFIED APPLICATION FOR EMPLOYMENT
(Please type or print in black ink.)

Name: _______________________________________________________________
Last First Maiden Nam e

Other Name(s): __________________________________________________________________

(Please provide any additional information relative to change of name, use of an assumed name, or nickname, necessary to enable
a check on your work or school record.)

Social Security Number: __________-_____-__________

Present Mailing Address: __________________________________________________________________

Street City State Zip

Permanent M ailing Address: ___________________________________________________________________

Street City State Zip

Telephone: Present: ( ) ______________ Permanent: ( ) _______________ Work: ( ) _________________

My signature below authorizes the school division to conduct a background investigation and authorizes release of information in connection
with my application for employment. This investigation may include such information as criminal or civil convictions, driving records, previous
employers and educational institutions, personal references, professional references, and other appropriate sources. I waive my right to access
to any such information, and without limitation hereby release the school division and the reference source from any liability in connection with
its release or use. This release includes the sources cited above and specific examples as follows: the local Sheriff, information from the Central
Criminal Records Exchange or either data on all criminal convictions or certification that no data on criminal convictions are maintained,
information from the North Carolina or other State Department of Social Services Child Protective Services Unit and any Locality to which they
may refer for release of information pertaining to any findings of child abuse or neglect investigations involving me.

Furthermore, I certify that I have made true, correct and complete answers and statements on this application in the knowledge that they may be
relied upon in considering my application, and I understand that any omission, false answered statement made by me on this application, or any
supplement to it will be sufficient grounds for failure to employ or for my discharge should I become employed with the school division.

Date: ____________________ Signature of Applicant: __________________________________

Please check the appropriate boxes. Indicate Position(s) Desired for W hich You Are
[ ] New Application Endorsed
[ ] Previous Application on File [ ] Teacher [ ] Administrator
[ ] Former Employee of the School Division [ ] Guidance [ ] Supervisor
[ ] Library [ ] Psychologist
Are you a U.S. Citizen? [ ] Visiting Teacher [ ] Other (Explain)
[ ] Yes [ ] No ________________________________________________
________________________________________________
If not, are you eligible to work in the U.S.?
[ ] Yes [ ] No List grade level(s) and/or subject area(s) in order of
preference:
________________________________________________
I. Educational and Professional Training (List Chronologically)

Type Dates of
Level of Year of
Name of School or University State Field of Study of Attendance
Education Graduation
Degree From - To

High School

College or
University

II. Student Teaching Experience and Teaching Experience (List chronologically all public and private
school teaching experience. DO NOT INCLUDE SUBSTITUTE TEACHING.)

Dates
School Division Position Held Grade and/or Total Full- Part-
Name of School State M/D/Y
City/County Subject Taught (Specify) Years Time Time
From-To

Total Years of Experience

III. Work Experience Other Than Teaching (List chronologically and attach a sheet if necessary.)

Employer City/County State Kind of Work Dates of

Employment

IV. Military Experience

Branch of Service Occupational Specialist Inclusive Dates Type of Discharge

(MOS)
V. Certification

A. If you have been issued a North Carolina teacher license, please submit a photocopy. A copy of my license is enclosed?
[ ] No [ ] Yes
List professional certificates held, state issued and date of expiration:

________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________

B. Have you taken the National Teacher’s Examination/Praxis? (If yes, please submit a copy of your scores.)

Core Battery: [ ] No [ ] Yes _________________________________________ Copy Enclosed? [ ] No [ ] Yes

(Month/Year) (CS) (GK) (PLT)

Specialty Area: [ ] No [ ] Yes _________________________________________ Copy Enclosed? [ ] No [ ] Yes

(Month/Year) (Subject) (Score)

VI. General Information

Month, Day and Year Available for Employment _____________________________________________________________________

Are you currently under contract? [ ] No [ ] Yes

If yes, where? _____________________________________________ Present Position ______________________________________

If presently employed, why do you wish to change employment? _________________________________________________________

Referral Source: [ ] Advertising/Posting [ ] Job Fair [ ] Employee [ ] Friend [ ] Other (Explain) ______________________________

Have you ever been refused tenure or a continuing contract? (If yes, explain on back) ..................... [ ] No [ ] Yes

Have you ever been fired, asked to resign from or suspended from a position or been subject to
disciplinary action? (If yes, explain on back) ....................................................................................... [ ] No [ ] Yes

Have you ever been convicted of or pleaded no contest to a crime other than minor traffic violations? (If
yes, explain on back) .......................................................................................................................... [ ] No [ ] Yes

Are any criminal charges or proceedings pending against you? (If yes, explain on back) .................. [ ] No [ ] Yes

Have you ever had a certificate or license revoked or suspended? (If yes, explain on back) ............... [ ] No [ ] Yes

VII. References

It is the applicant’s responsibility to have the following information submitted to the school system in order to be considered for
employment. ALL REFERENCES MUST BE CURRENT WITHIN ONE YEAR.

A. The names of at least three reference sources must be provided and must include current employer if employed or last employer if not currently
employed.

B. Applicants who are beginning teachers registered with a college placement office must include references from their student teacher supervisor(s)
and co-operating teacher(s) in the placement file or by listing names below.

Phone Number
Name of Reference Position/Relationship Mailing Address
Work Home
VIII. Extracurricular Activities

Indicate the years of experience in the activities listed below. Circle activities you are willing to coach/sponsor.

H igh School C ollege C ontract H igh School C ollege C ontract

E xtracurricular A ctivities E xtracurricular A ctivities
E xperience E xperience E xperience E xperience E xperience E xperience

Football Athletic Director

Basketball Athletic Trainer

Softball Debate

Track Drama

Cross Country Yearbook

Wrestling Literacy Magazine

Gymnastics Student Government

Field Hockey Honor Society

Golf Clubs

Tennis Cheerleaders

Volleyball Other

Soccer Other

IX. Other Information

To avoid conflict of interest, list any local School Board Member(s) or relative(s) in the school system and indicate
relationship. __________________________________________________________________________________________

Explain any physical or mental conditions which would adversely affect your ability to perform the duties of the position you
are seeking. If there are none, please indicate. ______________________________________________________________

In your own handwriting, please express your views on a current issue in education. If additional space is needed, please use
a separate sheet.

EQUAL OPPORTUNITY EMPLOYER

Hertford County Public Schools does not discriminate on the basis of race, color, national origin, age, religion, political affiliation, handicapping
conditions, or sex in its educational programs or employment. No person shall be denied employment solely because of any impairment that is unrelated
to the ability to engage in activities involved in the position or program for which application has been made.