APPLICATION FOR PROFESSIONAL EMPLOYMENT

Present Address
Street/PO Box	City	State	Zip

Permanent Address
Street/PO Box	City	State	Zip

Other Contact Information
Preferred Phone	Alternate Phone	Email

Position Applied For:

Can you submit proof of U.S. citizenship?     Yes     No

If not, please explain:

Have you ever been convicted of a felony or misdemeanor other than a minor traffic offense?     Yes     No

If yes, please explain:

Are you currently under contract?     Yes     No

If yes, please state when and where:

Why do you want to leave your current position?

Do you possess current professional certification as a teacher?     Yes     No
Certificate Number:
Years Experience:
Date Issued:
Date Expires:
Issuing State:
Degree on which certification was based:	BA       BA+18       MA       MA+30       DR

Subjects and grade levels certified to teach:

Educational Preparation - High school and beyond
Name of School	City/State	Start Date	End Date	Degree	Major

Professional Experience
Name of School	City/State	Employed From-To	Grades	Subjects	Reason for Leaving

Other Work Experience (Full Time Only)
From/To	Business Name	City	State	Type of Work	Reason for Leaving

Are you active in the National Guard or Reserve?     Yes     No

If so, to what extent?

Branch of Service:         Dates (month/yr to month/yr)

List any additional part-time or voluntary child-related work experience:

List participation in organizations and offices held:

List any extracurricular activities, sports, clubs, or activities you would be interested in conducting:

References
Give the name and address of three persons competent to speak of you as a teacher. Include present principal, department chair, and supervisor.
Ref 1 Name	Position	Institution	Street	City	State & Zip
Email:       Phone:
Ref 2 Name	Position	Institution	Street	City	State & Zip
Email:       Phone:
Ref 3 Name	Position	Institution	Street	City	State & Zip
Email:       Phone:

Use the space below for a personal statement, giving your estimation of your qualifications (strengths and weaknesses).

Use the space below to explain how employing you would benefit the Latta School District.

The following information must be available for consideration of candidacy. College Transcripts (First Year Teachers Only) Teaching Certificate

READ CAREFULLY BEFORE SIGNING and SUBMITTING My signature below indicates that I have completed this application for employment accurately and truthfully. I understand that misrepresentation of factual information is cause for dismissal should the Latta School District employ me. SIGNATURE:       DATE: Latta School District does not discriminate in the employment of staff based on sex, race, age, or handicapping conditions. The district complies with the requirements of Title IX of the 1972 Education Ammendment, Section 504 of the Rehabilitation Act of 1973, and Title VI of the Civil Rights Act of 1964 as well as other applicable civil rights laws. You are not required to disclose information about physical or mental limitations that you believe will not interfere with your ability to do the job. On the other hand, if you want the employer to consider special arrangements to accommodate a physical or mental impairment, you may identify that impairment in the space below and suggest the kind of accommodation you believe would be appropriate.

To complete the process of reviewing your application we will need your date of birth and Social Security Number. You
may voluntarily provide it below if you wish. If not, you MUST contact Sonya Rogers at 843-752-7101 to provide this information
so we can consider your application.

DOB (mm/dd/yyyy):
SSN: