West Bend - Mallard Community School District   

Teaching Application 

General Information                

Application Date:                       Date Available: 
First Name:      Middle Initial:     Last Name:
Social Security Number:
Are you eligible to work in the United States?   Yes   /   No  
Current Home Phone:      Work Phone:
Permanent Phone:
Current Address:


Permanent Address:

Positions(s) for which you are applying:

Are you available full time?   Yes  /   No
Are you willing to consider less than full time?  Yes  /   No
Are you under a teaching contract for next year?  Yes  /    No    Where?
Have you applied for your Iowa Teacher License?  Yes  /   No    
If so, which State(s)?
What certifications, endorsements or approvals have you achieved (including coaching authorization)?

Have you previously held a licensed position in an Iowa public school? Yes  /   No
District:
How many total years of teaching experience do you have?
Have you successfully completed an official probationary period in a public school district? Yes  /   No
If yes, what was the length of the probationary period?
Have you successfully completed a mentoring and induction program?  Yes  /   No
      If yes, when?   

     If no, have you completed:  

One Year

Two years but have been recommended for a third year.

Three years and am not being recommended for a professional license.

None.

Are you on a sex offender registry?  Yes  /   No
Are you on the Department of Human Services' child abuse registry?  Yes  /   No

Have you ever been convicted of a felony or misdemeanor (excluding traffic violations)?  
Yes  /   No
Please provide date, incident, city/state of charge:

Responding "yes" to any of the previous questions is not an automatic bar to employment.  The date of the offense, and the relationship between the offense and the position for which you are applying will be considered.

Are you able to perform, with or without reasonable accommodation, the  
essential job functions required of this position?  
          Yes  /    No   

If no, explain:
High School Attended:        Location:
Have you served in the Military?  Yes  /   No
If yes, please indicate the particular war(s) and/or conflict(s):
 



Education   
                 

College: Location:

Degree & Major/Minor:

Number of Hours Beyond Highest Degree:



Employment           

School District/Employer: 
Employer Address:

Supervisor's Name:     Supervisor's Phone Number:
Date Worked From:     Date Worked To:
Position:

Duties:
Reason For Leaving:


School District/Employer:
Employer Address:
Supervisor's Name:     Supervisor's Phone Number:
Date Worked From:     Date Worked To:
Position:

Duties:
Reason For Leaving: 


School District/Employer:
Employer Address:
Supervisor's Name:     Supervisor's Phone Number:
Date Worked From:     Date Worked To:
Position:

Duties:
Reason For Leaving: 



References           

Name: Reference's Employer & Address

 Position

 Home Phone

 Work Phone:

Application Verification           

I hereby certify that the above information, to the best of my knowledge, is true, accurate and complete.  Any misrepresentation or willful omissions of fact shall be sufficient cause for disqualification of this application or termination of employment.  I authorize verification of any of this information.  I authorize all current and former employers to release any information concerning my background.  I understand that this application is not a contract of employment.  I also understand that if hired, regardless of any oral representation to the contrary, the employment relationship is terminated-at-will.

Signature: _______________________________     Date: ________________

Complete this application form. Print it and send along with letter of application, resume, and credentials to:

Superintendent
West Bend-Mallard CSD
PO Box 247
West Bend, IA 50597
EOE/AA