Application Date: 
Date Available: 

First Name:  Middle Initial:  Last Name:  

E-mail Address: 

Note: Please check and double check your e-mail for any typos. When you submit this form you will receive a copy of the form IF you have entered the address correctly. This is a required

Social Security #: 
Please type your SSN using this format (where X = number) XXX-XX-XXXX

Are you currently employed by the Muscatine School district? Yes No   If so, what is your position?

U.S. Citizen:  Yes No         Are you legally eligible to work in the United States?  Yes No 

Current Home Phone:           Work Phone: 

Permanent Phone: 

Position(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 or do you have an initial Iowa Teacher License or a standard Iowa Teacher License?  Yes No  

Iowa Folder Number: 

Do you hold a license from another state?  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? 

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? 

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

If yes, please provide date, incident city/state of charge:

PLEASE NOTE: 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, I served in these wars and/or conflicts:

Educational and/or other Employment (begin with current/most recent)
*Teachers may include paid or volunteer activities other than classroom teaching

Student Teaching History

Employment History

Supervisor's Name:      Phone: 

Date Worked From:  Date Worked To:      Position: 

Duties and Responsibilities (include coaching and/or extracurricular activities):

Reason for Leaving:

Supervisor's Name:      Phone: 

Date Worked From:  Date Worked To:      Position: 

Duties and Responsibilities (include coaching and/or extracurricular activities):

Reason for Leaving:

Supervisor's Name:      Phone: 

Date Worked From:  Date Worked To:      Position: 

Duties and Responsibilities (include coaching and/or extracurricular activities):

Reason for Leaving:

References: List at least three who have evaluated your teaching skills and abilities.

Other Comments:

How did you learn about the position for which you are applying?

Authorization and Release

I HEREBY CERTIFY THAT THE STATEMENTS MADE BY ME IN THIS APPLICATION ALL RELATED INFORMATION WHICH I HAVE PROVIDED ARE TRUE, ACCURATE, AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

Yes No

I EXPRESSLY AUTHORIZE THE RELEASE TO THE EDUCATIONAL AGENCY RECEIVING THIS APPLICATION ANY RECORDS OR INFORMATION WHICH MAY REFER OR RELATE TO THIS APPLICATION FOR EMPLOYMENT, INCLUDING, BUT NOT LIMITED TO, RECORDS OF EDUCATIONAL INSTITUTIONS, LAW ENFORCEMENT OR CRIMINAL JUSTICE AGENCIES, AGENCIES MAINTAINING CHILD ABUSE RECORDS, AND PREVIOUS EMPLOYERS. I HEREBY RELEASE AND DISCHARGE THE EDUCATIONAL AGENCY RECEIVING THIS APPLICATION AND ANY RESPONSIBLE PERSON(S) EMPLOYED BY THE AGENCY FROM ANY AND ALL CLAIMS AND LIABILITY WHICH I MAY HAVE OR EVER CLAIM TO HAVE RELATING TO INFORMATION PROVIDED TO THE EDUCATIONAL AGENCY AS PART OF THIS APPLICATION FOR EMPLOYMENT.

Yes No

Signature of Applicant At the time of the personal interview the Applicant will be asked to sign any needed and necessary releases as a part of the interview process and/or employment. The interviewing Educational Agency may forward the Applicant Authorization and Release forms as a part of the interviewing process.

DATE ______________________

NAME _______________________________

SIGNATURE _________________________ (Mailed/Delivered)

For security, please enter the characters you see in the following image: