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Mineral County School District
Professional Application Form
5/23/2019

APPLICATION FOR PROFESSIONAL EMPLOYMENT

MINERAL COUNTY SCHOOLS

"Success For All Students: No Exceptions, No Excuses"

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Attachments for this application: Click to Upload Files
Please attach any docmentation or related items to this application.
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Name: *
Address:
City: *
State:
ZIP:
Home Phone: ()- Ext.
Cell Phone: ()- Ext.
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High School

City/State

Graduation Date




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College/University

Address

Degree Awarded

Date Awarded

Major/Minor





















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CERTIFICATION:
NOTE: If the answer to 1 or 2 is yes, please attach a copy of the certificate(s) if not already on file.  Also, please include a copy of your transcript(s) if not already on file.

1. Do you hold a West Virginia Teaching Certificate?

Yes  No  

2. Do you hold a valid teaching certificate from another state?

Yes  No  
If yes, what state?:
3. List your field(s) of certification, permits or authorizations and grade level(s) as shown on your certificate.
Field:
Grade(s):
Field:
Grade(s):
Field:
Grade(s):
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DISCLOSURE OF BACKGROUND INFORMATION: 
IF YOU ANSWER "YES" TO ANY QUESTION BELOW, SUBMIT WITH YOUR APPLICATION A COMPLETE NARRATIVE, INCLUDING DATES, LOCATIONS, SCHOOL SYSTEMS AND ANY OTHER APPROPRIATE INFORMATION.

1. Have you ever had adverse action taken against any application, certificate or license in any state?  Adverse action includes but is not limited to the following: letter of warning, reprimand, denial, suspension, revocation, voluntary surrender or cancellation.
Yes  No  
2. Have you ever disciplined, reprimanded, suspended or discharged from any employment because of allegations or misconduct? 
Yes  No  
3. Have you ever resigned, entered into a settlement agreement, or otherwise left employment as a result of alleged misconduct? 
Yes  No  
4. Is any action now pending against you for alleged misconduct in any school district, court, or before any educator licensing agency or other employment? 
Yes  No  

5. Have you ever been charged with, or convicted of, or under indictment for a felony? *

Yes  No  

6. Have you ever been charged with or convicted or a misdemeanor?  (For the purpose of this application, minor traffic violations should not be reported.)  Charges or convictions for driving while intoxicated (DWI) or driving under the influence (DUI) must be reported.  *

Yes  No  

FOR A "YES" ANSWER TO ITEMS 1-4, INFORMATION MUST BE PROVIDED UPON REQUEST.

*FOR A "YES" ANSWER TO ITEMS 5&6, THE FOLLOWING MUST BE FORWARDED UPON REQUEST:
1) JUDGMENT ORDER -OR- 2) FINAL ORDER -OR- 3) MAGISTRATE COURT DOCUMENTATION -AND- 4) ALL OTHER RELEVANT COURT DOCUMENTATION.

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PREVIOUS EMPLOYMENT: 
(Please list in chronological order and include Military Service.)

DATE FROM

DATE TO

EMPLOYER & LOCATION

TITLE/JOB DESCRIPTION

































Do we have permission to contact your previous employers?

Yes  No  
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REFERENCES: 
Please indicate if reference is employer or personal reference.  At least one reference must be an employment reference, if applicable.

NAME

PHONE #

EMPLOYER OR PERSONAL REFERENCE


*()- Ext.
Employer  Personal  
Relationship:

*()- Ext.
Employer  Personal  
Relationship:

*()- Ext.
Employer  Personal  
Relationship:
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As required by Federal laws and regulations, the Mineral County Board of Education does not discriminate on the basis of sex, race, color, religion, disability, age and national origin in employment and in the administration of any of its educational programs and activities.  Inquiries may be directed to Title IX Coordinator/Section 504 Coordinator, 304-788-4200; to the State Elimination of Sex Discrimination Project Coordinator, 304-558-7864; or to the U.S. Department of Education's Director of the Office of Civil Rights, 215-896-6795.

Read this paragraph carefully before submitting this application.

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment with Mineral County Schools and that the answers given by me are true and correct to the best of my knowledge.  I further certify that I, the applicant, have personally completed this application.  I understand that any omission or misstatement of material fact on this application or any other document used to secure employment will be grounds for rejection of this application and for immediate discharge if I am employed regardless of the time elapsed before discovery.

I acknowledge that this application, when submitted, will become the property of Mineral County Schools.

I further acknowledge that by clicking on the "Submit" button, I am indicating my intent to sign the relevant document and that this shall constitute my signature.

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