Hays Lodgepole School District

Contact Information

1) Name

2) Home Phone Number

3) Mailing Address

4) City, State, Zip Code

5) Cell Phone Number (optional)

6) Email Address (optional)

7) Position you are applying for

8) May we have permission to contact your current employer?

True

False

9) If "Yes", please provide contact information (optional)

Education

Please list the colleges/universities you have attended, the dates attended, and any degrees earned.

10) College/University Names / Dates Attended / Degrees Earned

11) Please list any Awards or Certificates you have received (optional)

12) Please describe your Community Service affiliations, if any (optional)

Credentials now held (including Emergency and Substitute)

13) Type

14) Expires (Date)

15) Type (optional)

16) Expires (Date)

17) Semester units beyond B.A. Degree (optional)

Employment Experience

18) Years (format yyyy to yyyy) (optional)

19) Employer (optional)

20) Employer Address (optional)

21) Employer Phone Number (optional)

22) Type of work performed (optional)

23) Years (format yyyy to yyyy) (optional)

24) Employer: (optional)

25) Employer Address: (optional)

26) Employer Phone Number: (optional)

27) Type of work performed: (optional)

28) Years (format yyyy to yyyy) (optional)

29) Employer (optional)

30) Employer Address (optional)

31) Employer Phone Number (optional)

32) Type of work performed (optional)

33) Type of work performed (optional)

34) Type of work performed (optional)

References (other than relatives):

35) Name

36) Phone Number

37) Relationship to applicant

38) Name

39) Phone Number

40) Relationship to applicant

41) Name

42) Phone Number

43) Relationship to applicant

44) If you answered "Yes", please provide information explaining the circumstances (optional)

45) Have you ever been arrested for anything other than a minor traffic violation?

True

False

46) If you answered "Yes", please provide information explaining the circumstances (optional)

47) If you answered "Yes", please provide information explaining the circumstances (optional)

48) If you answered "Yes", please provide information explaining the circumstances (optional)

49) If you answered "Yes", please provide information explaining the circumstances (optional)

50) Do you have a physical condition which may limit your ability to perform the job for which you have applied?

True

False

History And Limitations

51) Have you ever been dismissed or asked to resign from any teaching position?

Yes

No

52) Have you ever been employed by Hays Lodgepole School District #50 in any capacity?

Yes

No

53) Have your credentials ever been suspended or revoked?

Yes

No

Attest And Sign

Background Check and Statement of Truthfulness

If employed, you will be required to furnish information on age, citizenship clearance through the Department of Justice, freedom from communicable disease, and right to work in this country, if applicable.

I certify that all statements made hereon are true and correct to the best of my knowledge. I understand that any false statements made on this application may be cause for non-employment or for dismissal if employed.

I hereby authorize any investigation to obtain information required by this application.

54) Type Name

Resume' and Additional Information

If you would like to submit a resume' or additional documents, please email them to Jessica Stiffarm at jstiffarm@hlpschools.k12.mt.us

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