Professional Application (Form)

Professional Application

APPLICATION FOR PROFESSIONAL PERSONNEL

Karnack Independent School District
PO Box 250, 655 Fason Street
Karnack, Texas 75661
Phone 903-679-3117   Fax 903-679-4252
An Equal Opportunity Employer*

Date of application 


Personal Data

Name
Last   First   Middle Initial 

Current Address

Street/Box  City  State 

Zip Code 

Email address 

Other address where you may be reached

Street/Box  City  State 

Zip Code 

Home Phone  Cell Phone   Other Phone 

Other name that may appear on record 
(Used for certification, reference, and criminal background checks)


Position Data

List the Position(s) for which you are applying 

Credentials included with application:

Resume

All teaching and professional certificates and licenses

All transcripts showing degree

Date you can begin work 

Have you been employed by Karnack ISD in the past? Yes No

If you answered yes, provide dates of employment 


Education/Training

Name and location of schools attended 

Course of study and major/minor 

Diploma, degree, certificate, or license granted 

Year graduated (college only) 


Name and location of schools attended 

Course of study and major/minor 

Diploma, degree, certificate, or license granted 

Year graduated (college only) 


Certificates or Licenses Currently Held

None

Valid Texas

Valid Other States 

Texas One-Year (out-of-state/country: Expiration date: 

Other: 

Category/Level(s) of Certification:   

Areas of Specialization/Supplement Certificates/Endorsements (as listed on certification)

  

  


Teaching Experience

List teaching experience beginning with the most recent years.

Name and location of school 

Type of assignment 

Dates taught 

Principal's name and phone 

Reason for leaving 


Name and location of school 

Type of assignment 

Dates taught 

Principal's name and phone 

Reason for leaving 


Name and location of school 

Type of assignment 

Dates taught 

Principal's name and phone 

Reason for leaving 


Other Work Experience

Please provide a list of all other jobs or administrative positions you have held in the past 10 years. Attach additional sheets if necessary. Attach resume if available.

Employer name and location 

Position/title held 

Dates employed 

Supervisor's name and phone 

Reason for leaving 


Employer name and location 

Position/title held 

Dates employed 

Supervisor's name and phone 

Reason for leaving 


References

Please list references the district can contact regarding your work history.

Full name of reference 

School District/firm name 

Mailing Address 

Position/title 

Area code/phone number 


Full name of reference 

School District/firm name 

Mailing Address 

Position/title 

Area code/phone number 


Full name of reference 

School District/firm name 

Mailing Address 

Position/title 

Area code/phone number 


Full name of reference 

School District/firm name 

Mailing Address 

Position/title 

Area code/phone number 


General Information 

Do you have a relative who serves on the Board of Education or is an employee of Karnack ISD?

Yes No    If yes, please provide the relative's name and relationship

Have you ever been convicted of, pled guilty or no contest (nolo contendre) to, or received probation, suspension, or deferred adjudication for a felony or any offense involving moral turpitude (including, but not limited to, theft, rape, murder, swindling, and indecency with a minor)? Yes  No

If yes, please state where, when, and the nature of the offense

(A felony conviction is not an automatic bar from employment. The district will consider the nature, date, and relationship between the offense and the position for which you are applying)


Verification

I hereby affirm that all information provided in this application is true and accurate to the best of my knowledge and understand that any deliberate falsifications, misrepresentations, or omissions of fact may be grounds for rejection of my application or dismissal form subsequent employment.

I authorize the references listed on the previous page to give you any and all information concerning my previous employment and any pertinent information that may have, personal or otherwise, and release all such parties from liability for any damage that may result from furnishing the same to you.

I understand that the district is required by Texas Education Code to review criminal history of applicants.

Pease type full name    Date 

I understand that check this box constitutes a legal signature confirming that I acknowledge and warrant the truthfulness of the information provided in this document.

This application becomes the property of the district. The district reserves the right to accept or reject.


Applicants for all positions are considered without regard to race, color, sex, (including pregnancy), national origin, religion, age, disability, genetic information, veteran or military status, or any other legally protected status. Additionally, the district does not discriminate against an applicant who acts to oppose such discrimination or participates in the investigation of a complaint related to a discriminating employment practice.


The district Title IX coordinator is: Amy Dickson
                          Superintendent of Karnack ISD
                          PO Box 250
                          Karnack, TX 75661


CRIMINAL HISTORY INFORMATION REQUEST

Confidential


The Karnack Independent School District is required by Texas Education Code Chapter 22, Subchapter C to review the criminal history of applicants, employees, independent contractors, student teachers, and certain volunteers. The information requested below is necessary to obtain criminal history information.

Last Name   First Name   

Middle Name 

Social Security Number 

Date of birth 

Driver's License Number 

Mailing Address

Street   City 

State   Zip 

Sex: Male  Female

Ethnicity: Black  White/Other

I understand that the information I am providing about age, sex, and ethnicity will not be used to determine eligibility for employment but will be used solely for the purpose of obtaining criminal history record information.

Pease type full name    Date 

I understand that check this box constitutes a legal signature confirming that I acknowledge and warrant the truthfulness of the information provided in this document.

This form will be removed from the application and filed separately in the HR office..


DPS Computerized Criminal History (CCH) Verification

(Agency Copy)

I, , have been notified that a Computerized Criminal History CCH) verification check will be performed by accessing the Texas Department of Public Safety Secure Website and will be on name and DOB identifiers I supply.

Because the named based information is not an exact search on only finger print record searches represent true identification to criminal history, the organization conducting the criminal history check for background screening is not allowed to discuss any criminal history record information obtained using the name and DOB method. Therefore, the agency may request that I have a fingerprint search performed to clear any misidentification based on the result of the name and DOB search.

For the finger printing process I will be required to submit a full and complete set of my fingerprints for analysis through the Texas Department of Public Safety AFIS (Automated Fingerprint Identification System). I have been made aware that in order to complete this process I must make an appointment with LT Enrollment Services, submit a full and complete set of my fingerprints, request a copy be sent to the agency listed above, and pay a fee of $24.95 to the fingerprinting services company, L1 Enrollment Services.

Once the process is completed and the agency receives the data from DPS, the information on my fingerprint criminal history may be discussed with me.

(This copy must be retained on file by your agency. Required for future DPS audits)

Pease type full name    Date 

I understand that check this box constitutes a legal signature confirming that I acknowledge and warrant the truthfulness of the information provided in this document.

Karnack Independent School District

Agency Representative __________________________________________________

Signature of Representative ___________________________________________________

Date ____________________________________

For Agency use only

Please Check and Initial each available space

CHH Report Printed ___ Yes ___ No ____ Initial

Hire: ___ Yes  ___ No _____ Initial

Date: _______________________________________

Destroy Date _________________________________



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