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Date Received ________


Interview Date________



105 East Country Club Lane

Covington, Virginia 24426







Applicant’s Full Name __________________________________________________________________

(Last)                           (First)               (M.I.)                           (Maiden Name)

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.)


Present Mailing Address________________________________________________________________

(Street)                                     (City)                           (State)              (Zip)


Permanent Mailing Address _____________________________________________________________

(Street)                                     (City)                           (State)              (Zip)


Telephone Numbers:

Present:_____________________      Permanent:____________________   Work:___________________


Social Security Number: _______________________ (Note: Completion of number is optional. Failure to submit social security number on this form will not prohibit employment consideration. Social Security number may be required on other forms prior to employment.)


My signature below authorizes the Joint Board 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 education institutions, personal references, and other appropriate sources. I waive my right of 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 of either data on all criminal convictions or certification that no data on criminal convictions are maintained, information from the Virginia 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 for grounds for failure to employ or for my discharge should I become employed with the school division.



Date_________________________  Signature of applicant _______________________________________



Are you US Citizen?                                         LIST BELOW POSITION FOR WHICH YOU ARE APPLYING:

Yes ___  No____                                            _____________________________________________________


If not, are you eligible to work in the US?          _____________________________________________________

Yes ___ No ___




  1. Educational And Professional Training (List chronologically.)


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

High School

College or University            
Trade or Technical School            
Other Formal Training            



  1. Student Teaching Experience (List chronologically and include any internships.)


Name of School School Division City/County State Grade Level and/or Subject Dates Personnel Use



III.                 Teaching Experience (List chronologically all teaching experiences. DO NOT INCLUDE SUBSTITUTE TEACHING.)


Name of School School Division City/County State Position Held Grades and/or Subjects Taught (Specify) Dates

Mo/Day/Yr. From – To

Total Years

Full Time


Part Time


Personnel Use



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


City/County State Kind of Work Dates of Employment Personnel Use


  1. Military Experience


Branch of Service
Occupational Specialist (MOS) Inclusive Dates Type of Discharge










  1. Certification
 A. If you have been issued a Virginia certificate, please submit a photocopy.  Copy Enclosed? No ___ Yes____

Type of VA Certificate: Provisional______ Collegiate Professional______ PG Professional____ Pupil Personnel___  VIE___


Year of Expiration of Virginia Certificate __________  Endorsement(s) ____________________________________________




Have you applied for a Virginia certificate?  No____  Yes ____ When _______ Check if statement of eligibility enclosed ___


  1. If you have been issued a certificate in another state, please submit a photocopy. Copy Enclosed? No_____ Yes _____


State ________ Expiration Date _____ Certification/Endorsements ______________________________________________


State ________ Expiration Date_____ Certification/Endorsements _______________________________________________


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


Core Battery:   No____ Yes____      __________________   ________  _______  _______  Copy Enclosed? No___ Yes___

Month /Year                      CS            GK            PK


Specialty Area: No ___ Yes___     __________________   _________________  ________ Copy Enclosed? No___ Yes___

Month/Year                               Subject                    Score



VII.           General Information


Month, Day and Year Available for employment ________________________  Are you under contract? No______ Yes____


If yes, where? ___________________________________ Present Position________________________________________


If presently employed, why do you wish to change? __________________________________________________________


If under contract, what type: Annual/Probationary_____ Other___ (explain)____________________Continuing/Tenure ____


If under contract, have you checked and can you be released if you are offered another position? Yes_____ No____


If not under contract now, have you ever held a continuing contract in Virginia? No_____ Yes _____


If yes, city school division(s) and date(s) ___________________________________________________________________


Referral source:  Advertisement/Posting ______ 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 discharged or requested to resign from a position? (If yes, explain on back.) No____ Yes____


Have you ever been convicted of a violation of law other than a minor traffic violation? (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 ___


Are any criminal charges or proceedings pending against you? (If yes, explain on back) No___ Yes___


Have you been convicted of any offense involving sexual molestation, physical or sexual abuse, or rape of a child? (If yes, explain on back.)                                                                                                                                                                No ____ Yes ___





VIII.        References

It is the applicant’s responsibility to have the following information provided to the School Division in order to be considered for employment:


  1. The names of at least three reference sources must be provided. The names of their current employer (if employed) or most recent employer (if currently unemployed) must be provided.


  1. Unless included in Placement File, applicants with work experience must provide recommendations from principals and/or superintendents from all contracted educational work experiences within the past three years. If experience was not within the past three years, provide references from last contracted experience.


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


  1. As indicated above, a Placement File is being sent _____, and/or references are listed below:


Name Reference Position/Relationship Mailing Address Phone Number


  1. Other Information

To avoid conflict of interest, list any Joint Board of Control member or employee relative(s) at the Center and cite relationship.









Additional remarks and/or explanations from section VII General Information.












Please provide any additional information you desire that will afford an additional understanding of your qualifications. Your goals, objectives, philosophy, and other background factors are of special interest.





The Joint Board of Control 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 which is unrelated to the ability to engage in activities involved in the position or program for which application has been made.


The Joint Board Of Control Is An Equal Opportunity Employer


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