*Please Print and fill out.  Send completed form to:
Coulee Hartline School District
Box 428 / 410 Locust Street
Coulee City, WA 99115

Coulee-Hartline School District
Substitute / Teacher Employment Application
* indicates a required field.


Full Name: Last * First * Middle
Social Security Number * - -
Other Names (Provide additional information relative to change of name or nickname necessary to enable a check on your work or school record):

Street: *
City State Zip: * * * -
Home Phone: *( ) * -
Work Phone: ( ) - ext
Mobile Phone: ( ) -
E-mail:
Are you currently legally eligible for employment in the United States? * Yes No
Have you worked for the Coulee-Hartline School District before? * No Yes If yes, when and in what capacity?

Have you applied for a position with Coulee-Hartline School District previously? * No Yes If yes, when and for what position?

Have you ever been dismissed or non-renewed from any employment? * No Yes If yes, when and by what employer?

Has your license ever been revoked? * No Yes If yes, please explain:

EDUCATIONAL BACKGROUND (Training Beyond High School)

College/University Name & Location

Dates Attended

Major Field

Degree Conferred & Year

From

To

*

*

*

*

*

TEACHING EXPERIENCE
Teaching experience (under contract): years. If Almira experience, specify school and years:

Subject or grades taught:

Do you have an application on file for a regular teaching position? No Yes

TEACHER CERTIFICATION

Areas of Certification

Endorsements

Endorsement Expires (mm/dd/yy)

Issuing State

*

*

*

*

CREDENTIAL INFORMATION


College or other placement office
Name credentials are listed under

STUDENT TEACHING EXPERIENCE: (List chronologically, most recent first, and include any internships or practicum.)

Name of School

Mailing Address/Phone

Cooperating Teacher

Grade Level and/or Subject

Dates

TEACHING EXPERIENCE: (Under contract only - please do not include substitute teaching)

Name of School

Mailing Address/Phone

Your Supervisor

Position Held, Grades and/or Subjects Taught

Dates

OTHER WORK HISTORY (Non-certified teacher applicants must submit a comprehensive resume with complete work history)

Employer

Address/Street/
City/State/Zip

Telephone

Your Supervisor

Your Position

Dates of Employment

With respect to employment and personnel operations, the Coulee-Hartline School District (ASD) does not discriminate on the basis of religion, race, creed, color, national origin, ancestry, age, sex, physical appearance, marital status, disability, arrest or conviction record, membership in the National Guard, state defense force, or any reserve component of the military forces of the United States or this state or political belief, sexual orientation, less than honorable discharge, source of income or the fact that an individual is a student.

I certify that the answers given by me to the foregoing questions and/or statements are complete, true, and correct to the best of my knowledge and without misrepresentation or omissions of any kind. I further understand that the making of any false or misleading statement or willful omission from or on this Employment Application, or any other document, may be used to deny me employment, or if employed, used for discipline, including termination from employment. I understand that the District shall not be held liable in any respect if my employment is terminated because of false or incomplete statements, answers or omissions made by me on this Employment Application or any other document. I authorize the Coulee-Hartline School District to make any investigation of my employment history and any other information related to my suitability for employment and authorize any employment reference(s) to disclose to the Coulee-Hartline School District any such information they may have regarding me. In consideration of the School District's review of this application, I hereby release the District, its Board, and its agents, as well as all providers of information, from any liability and for any damage which may result from the furnishing and receiving of this information. A copy of this authorization and release is as valid as the original and should be recognized as such.

VOLUNTARY AFFIRMATIVE ACTION SURVEY

To All CHSD Applicants:
As an Affirmative Action Employer, we must comply with various local, state and federal regulations. This includes the continuous recordkeeping and periodic reporting of the race and gender status of applicants for employment. To assist us in complying with governmental agency requirements, please complete the following survey. The survey data is considered confidential and will be used only for statistical and reporting information related to our applicant population.

SURVEY INFORMATION

Position(s) for which you are applying:
1st Choice
2nd Choice
3rd Choice

Please indicate the primary source of information which prompted you to apply for the job vacancy.


Gender:

Race/Ethnic Group:

Disabled: No Yes No Response