Covered Bridge Special Education District Online Application
1320 Walnut Street, Terre Haute, IN 47807

TEACHER APPLICATION FORM


Please indicate which position you are applying for: Date of Application:

Last Name First Name Middle or Maidden Name

Temporary Address
City State Zip Telephone

Permanent Address
City State Zip Telephone

Previously employed by the Covered Bridge Special Education District?YesNo
If Yes: Contract Teacher Sub-Teacher Other

Name under which transcripts and employment records may be identified if other than your present name:

LICENSE
Applicant must possess an Indiana certificate or present evidence showing eligibility for an Indiana certificate.
Type or kind of license
State
Expiration Date
Serial No.
Subject and/or grades

TEACHING PREFERENCES IN AREA OF CERTIFICATION
A. Elementary - List in order of preference.
B. Secondary - List in order of preference.
C. Other - (Music, Art, Physical Education, Vocational, Etc.) Indicate grade level & List in order of preference.

TEACHING AND/OR ADMINISTRATIVE EXPERIENCE
NAME AND LOCATION OF SCHOOL (Begin with most recent experience) GRADES OR SUBJECTS FROM TO REASON FOR LEAVING

STUDENT TEACHING EXPERIENCE
SCHOOL AND EXPERIENCE GRADES OR SUBJECTS FROM TO SUPERVISING TEACHER

MILITARY EXPERIENCE
Branch of service: Rank:
Date of beginning of active service:
Date of separation:
Number of months of active duty:
Type of discharge:

IMPORTANT SALARY INFORMATION
EXPERIENCE CREDIT (Subject to verification):
Years in public schools teaching: CBSED Substitute Teaching: Bachelor's Degree
Number of years non-public schools teaching: School Year Bachelor's+Hrs
Number of years military credit:
(Form DD 214 Required)		 School Year Master's Degree
Total: School Year Master's+Hrs
INDIANA TEACHER RETIREMENT NUMBER: School Year Ed. S. Degree
SOCIAL SECURITY NUMBER: School Year Ed.S.+Hrs
Doctorate

WORK EXPERIENCE OTHER THAN TEACHING
NAME AND LOCATION OF SCHOOL (Begin with most recent experience) GRADES OR SUBJECTS FROM TO REASON FOR LEAVING

EDUCATION INFORMATION
NAME OF INSTITUTION (CITY & STATE) DATES OF GRADUATION MAJOR / MINOR DEGREE
HIGH SCHOOL
UNDERGRADUATE
GRADUATE
POST-GRADUATE
OTHER

Undergraduate Grade Index Out of Possible

Graduate Grade Index Out of Possible

REFERENCES
Provide the names of three or more people including supervision, principals, department heads, or college professors under whom you have worked. Please indicate a date after which we may contact these people for reference information.
NAME POSITION PRESENT ADDRESS & TELEPHONE NUMBER DATE

PERSONAL
LIST ANY EXTRA CURRICULAR ACTIVITIES:
High School:
College:

DESCRIBE ANY SPECIAL ASSIGNMENTS AND/OR PROJECTS:
High School:
College:

LIST COMMUNITY AND/OR CAMPUS LEADERSHIP/AWARDS/HONORS/VOLUNTEERISM:
High School:
College:

If any members of your family are employed with the Covered Bridge Special Education District, please list with relationship:
Name Relationship Name Relationship



APPLICANTS STATEMENT:
The Covered Bridge Special Education District is interested in employing outstanding teachers. In the space provided below, please indicate your beliefs about public school education and what you would contribute to our students and school community if you are selected as a member of our staff.

  • If you are now working, is your conduct as an employee or the quality of your work the focus of any investigation by your current employer?

    Yes No If yes, explain the circumstances in the space provide.


  • Have you ever resigned from a job after disciplined by your employer or after being offered the opportunity to resign rather than be terminated?

    Yes No If yes, explain the circumstances in the space provide.


  • Have you ever been investigated for, chared with or plead guilty or "no contest" to any crime involving the sexual abuse of any person or indecency with a minor?

    Yes No If yes, explain the circumstances in the space provide.



  • Have you ever been charged with a crime, other than a minor traffic offense, where the court has deferred further proceedings without entering a finding of guilt or placed you on probation or in a public service or education program?

    Yes No If yes, explain the circumstances in the space provide.


  • Have you ever been convicted of a crime?

    Yes No If yes, list all and explain the circumstances in the space provide.

I authorize the Covered Bridge Special Education District to check my employment history, including without limitation, reference check, and to seek the release of investigatory infomation, including a "limited criminal history", possessed by any private or public employers or local, state or federal agencies to provide the Covered Bridge Special Education District any information they may release concerning the matters described herein, and I will coopoerate to the extent necessary to obtain the release of this information.

I expressly waive in connection with any request for, or provision of such information, any claims or causes of action, including without limitation, defamation, infliction or emotional distress, invasion of privacy, or interference with contractual relations that I might otherwise have against the Covered Bridge Special Education District, its officials, employees, trustees, or agents or against, or against any provider of such information.

After you have completely read this authorization and release of all claims, and you expressly agree to the terms set out herein, please type the words "I Agree" in the space provided here.


THE COVERED BRIDGE SPECIAL EDUCATION DISTRICT IS AN EQUAL OPPORTUNITY EMPLOYER.
This application will remain on file for one (1) year.