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Hermitage R-IV Public Schools
P.O. Box 327
Hermitage, MO 65668

APPLICATION FOR TEACHING OR ADMINISTRATIVE POSITION

 

Section I. General Information  

Name     SSN

Present Address     Phone #

Permanent Address     Phone #

Email Address

 

Position Applied For

Elementary Applicants Indicate Grade Level in Order of Preference:

Choice 1.       Choice 2.       Choice 3.

 

Secondary Applicants Indicate Subject Areas in Order of Preference:

Choice 1.     Choice 2.     Choice 3.

Date Available

 

Section II. Professional Preparation  

HIGH SCHOOL:

Name of School Attended
 		 City and State Approximate number of students Number of Years Attended Date of Graduation

High School Attended or Honors

Any person having inquiries concerning compliance with the regulations implementing Title VI of the
Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, and Section 504 of the Rehabilitation Act of
1973, or other applicable nondiscrimination laws, is directed to contact: Superintendent, Hermitage R-IV,
P.O. Box 327, 302 E. Polk St., Hermitage, MO 65668 (417) 745-6417

 

COLLEGE:

Name of School Attended
 		 City and State Dates Attended From - To Number of Years Attended Date of Graduation Degree Semester Hours

College Activities or Honors

Undergraduate Major     Undergraduate Minor

Graduate Major

 

 

Section III. Work Experience  

Teaching or Administrative Experience (list more recent position first):

Position School & Location Dates Inclusive Reason for Leaving

Total Years of Teaching     Administration     Present Salary

 

Experience Other than Teaching

Type of Work Firm and Location Dates Inclusive Reason for Leaving

 

 

Section IV. References

Include those best qualified to discuss your fitness for the position.  Superintendents and principals under whom you have worked should be included.
 
Name Position Address Telephone Number

 

Placement credentials on file at:

 

 

Section V. Additional Information and Certification

Subjects or grades for which you hold a Missouri certificate:

List coaching or other extracurricular activities you feel qualified to direct:

Are you under contract for next year in any school district?    Yes    No

If employed, would you be willing to teach in Hermitage at least two years?    Yes    No
If no, please explain.

Membership in professional, honorary, or civic organizations.

Have you ever been discharged or asked to resign from a position in the past five years?

Have you ever been arrested, indicted, or convicted of any law violations other than misdemeanors?     If yes, please explain.

Please add any additional information you wish to provide.

 

 

I certify the information provided in this application is accurate and complete to the best of my knowledge.  The superintendent of Hermitage R-IV Schools, or a designated representative, is hereby authorized to contact persons listed as references, obtain and examine my placement credentials, and otherwise investigate my personal background and employment experience.

  
 



Signature of Applicant

  



Date of Application

  
             
   

   
             
   

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