NAME_______________________________________________________________ Last First Middle Social Security No.______/_____/______

___Application Complete ___Transcript ___Certification ___Test Results ___Letter of Reference

PERMANENT ADDRESS ________________________________________(________)______________________ Street City State Zip Area Code Telephone No. PRESENT ADDRESS____________________________________________(________)_____________________ Street City State Zip Area Code Telephone No.

MONTGOMERY COUNTY BOARD OF EDUCATION Certified Employee Application

Fostering a Culture of Excellence for All DATE________________________

Mail To: Montgomery County Schools Certified Applications P. O. Box 315 Mount Vernon, GA 30445 Phone (912) 583-2301 Facsimile (912) 583-4822

FOR THE POSITION OF:

(If Elementary teacher, indicate grades in order of preference: if secondary teacher, indicate subject certified)

Type of Georgia Certificate held or for which you are qualified:

TYPE

ALL AREAS OF CERTIFICATION/CONCENTRATION

Valid Georgia professional certification in the assigned teaching field. Must have Highly Qualified status as defined by NCLB and the Georgia Department of Education/GaPSC. When could you begin work here? _____________________________________________________________ *Please Note: Applications are not complete without your official college transcript, teaching certificate, Praxis scores, and 3 letters of reference. AN EQUAL OPPORTUNITY EMPLOYER: The Montgomery County Board of Education does not discriminate on the basis of race, color, national origin, sex, physical handicap, religion, or age in the education and employment policies under which it operates.

PERSONAL DATA 1. Have you ever failed to have a contract renewed? Yes____ No____If yes, attach explanation. 2. Have you successfully completed three continuous years with another Georgia public school district thereby attaining tenure under the Georgia Fair Dismissal Law?_________________________________ If yes, then complete the following: School; _____________________________________________________________________________ District System: ______________________________________________________________________ City, State, Zip Code: __________________________________________________________________ Date Employed: From____________ Mo/Yr

To_________________ Mo/Yr

3. Give Name, address and telephone number of a person who will always know your address: ___________________________________________________________________________________ 4. List honors and professional activities: ___________________________________________________________________________________ ______________________________________________________ 5. State briefly your reason for desiring employment with the Montgomery County School System. ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Have you ever been placed on disciplinary probation or been terminated from a job, college, or university: YES______NO______If yes, attach an explanation. Have you ever been convicted of a violation of any Federal Law, State Law, County, or Municipal Law, regulation or ordinance? (Disregard events before your 16th birthday and minor traffic violations.) YES____

NO____ If Yes, attach an explanation.

If you have completed a placement file with a college placement office, give the name and address of the office from which it may be obtained.

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EDUCATION NAME OF SCHOOL AND LOCATION: (Including High School, College, Graduate Work & Summer Sessions.)

Dates Attended From

PRACTICE TEACHING: Name of School & Location From

Degree Awarded:

Major/Minor:

Grade or Subject Taught

Name of Principal or Supervising Teacher

To

Date To

TEACHING and/or EDUCATIONAL ADMINISTRATION EXPERIENCE School System/BOE Address/Phone Number:

Name of School & Supervisor/Principal:

Grade & Subject(s):

Reason for Leaving:

Dates of Employment:

WORK EXPERIENCE OTHER THAN TEACHING Name of Employer:

Address

Nature of Work

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Inclusive Dates From To

MILITARY EXPERIENCE Branch of Service::

Highest Rank:

Type of Discharge:

Years of Service:

(Attach copy of DD Form 214)

Have you completed the technology competency requirement? Yes______________ No_______________ COMPLETE NAMES AND ADDRESSES ARE NECESSARY FOR SUCCESS IN CHECKING REFERENCES. Please reference persons qualified to give information to show your fitness for the position you seek. Be sure to include your former administrators if you are an experienced teacher. For beginning teachers, include college supervisors and student teaching supervisors. Please attach at least three reference letters from individuals familiar with your work. Current Supervisor ___________________________________________ OK to contact __________ NAME

Please notify me before contacting __________ ADDRESS

POSITION

TELEPHONE

I certify that the information given on this application is accurate to the best of my knowledge. I agree that, if employed, I will abide by the policies and regulations of the Montgomery County Board of Education. Date __________

Signature of Applicant ___________________________

NOTE: All new certified employees hired by the Montgomery County Board of Education will be required to undergo a fingerprinting and criminal-records background check. Revised 060514 Page 4