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GALAX CITY PUBLIC SCHOOLS
223 Long Street
Galax, Virginia 24333
Phone: (276) 236-2911
Fax: (276) 236-5776
EMPLOYMENT APPLICATION FOR LICENSED PERSONNEL
 
 
 
Applicant's Name:
  Last First Middle
Other Name(s):
  (Please Provide any additional information relative to change of name, use of an assumed name, or nickname, necessary to enable a check on your work or school record.)
Present Mailing Address:
Street: City:
State: Zip:
 
Permanent Mailing Address:
Street: City:
State: Zip:
Telephone Numbers:
Present: Permanent: Work:
Email:
Please Note: While not required for this form, your Social Security number will be required on other forms prior to employment.
      Submission of this application authorizes the school division to conduct investigative consumer reports and authorizes release of information in connection with my application for employment. This investigation may include such information as criminal or civil convictions, driving records, previous employers and educational institutions, personal references, professional references, and other appropriate sources. I waive my right of access to any such information, and without limitation hereby release the school division and the reference source from any liability in connection with its release or use. This release includes the sources cited above and specific examples as follows: the local Police Department, information from the Central Criminal Records Exchange of either data on all criminal convictions or certification taht no data on criminal convictions are maintained, information from the Virgina or other State Department of Social Services Child Protective Services unit and any locality to which they may refer for release of information pertaining to any findings of child abuse or neglect investigations involving me.
      Furthermore, I certify that I have made true correct and complete answers and statements on this application in the knowledge that they may be relied upon in considering my application. I understand that any omission, false statement on this application, or any supplement to it, will be suffient grounds for failure to employ or for my discharge should I become employed with the school division.
Date: Applicant (type your full name):
Select the Appropriate Item: Indicate Position(s) Desired For Which You Are Endorsed:
If Other, Explain:
Are you a U.S. citizen? List grade level(s) and/or subject area(s) in order of preference:
If not, are you eligible to work in the U.S.?
I. EDUCATIONAL AND PROFESSIONAL TRAINING (List chronologically)
Level of Education Name of School or University State Field of Study Type of Degree Year of Graduation Date of Attendance From ... To
High School
College or University
II. STUDENT TEACHING EXPERIENCE (List chronologically and include any internships.)
Name of School School Division and ADDRESS State Grade Level and/or Subject Dates
III. TEACHING EXPERIENCE (LIst chronologically all teaching experience. Do not include substitute teaching)
Name of School School Division and ADDRESS State Position Held Grades/Subjects Taught (Specify) Dates Mo/Day/Yr Total Yrs. Full Time (X) Part Time (X)
IV. WORK EXPERIENCE OTHER THAN TEACHING (List chronologically)
Employer City/County State Kind of Work Dates of Employment
V. MILITARY EXPERIENCE
Branch of Service Occupational Specialist (MOS) Inclusive Dates Type of Discharge
VI. CERTIFICATION
A. If you have been issued a Virginia license, please submit a scanned copy to application@gcps.k12.va.us
Type of Virginia License:
Year of Expiration of Virginia License: Endorsement(s):
Have you applied for a Virginia License:
When:
B. If you have been issued a license in another state, please submit a scanned copy to application@gcps.k12.va.us
State: Expiration Date: Licensure/Endorsements:
State: Expiration Date: Licensure/Endorsements:
C. Please indicate your licensure assessments. (Submit a scanned copy of each score to application@gcps.k12.va.us)
Praxis I:
Mo. Yr. Reading Writing Math
Praxis II:
Mo. Yr. Subject Score
SAT:
ACT:
VCLA:
Mo. Yr. Reading Writing
VRA:
Mo. Yr. Score
VII. GENERAL INFORMATION
Month, Day, and Year available for employment: Are you under contract?
If under contract, where?Present Position:
If presently employed, why do you wish to change?
If under contract, what type:
If under contract, have you checked and can you be released if you are offered another position?
If not under contract now, have you ever held a continuing contract in Virginia?
If yes, cite school division(s) and date(s)
Referral Source (Check one):
Have you ever been refused tenure or a continuing contract?
Have you ever been discharged or requested to resign from a position?
Have you ever been convicted of a violation of law other than a minor traffic violation?
Have you ever had your license revoked or suspended?
Are any criminal charges or proceedings pending against you?
Have you been convicted of any offense involving the sexual molestation, physical or sexual abuse, or rape of a child?
VIII. REFERENCES
It is the appicant's responsibility to provide the School Division with the following information in order to be considered for employment.

A. The names of at least three references must be provided and must include current employer if employed, or last employer if not currently employed.

B. Unless included in Placement File, applicants with work experience must provide recommendations from principals and/or superintendents from all contracted educational work experience within the past three years. If experience was not within the past three years, provide references from the last contracted experience.

C. As indicated above:
Name of Reference Position/Relationship Mailing Address Phone Number
1.
2.
3.
IX. EXTRACURRICULAR ACTIVITIES
Indicate the number of years experience in the activities listed below. CHECK activities you are willing to coach/sponsor:
  High School Experience College Experience Contract Experience   High School Experience College Experience Contract Experience
Football Athletic Dir.
Basketball Athletic Tr.
Baseball Forensics
Softball Debate
Track Drama
Cross Country Yearbook
Wrestling Newspaper
Band/Flag Corp. Lit. Magazine
Chorus Student Govt.
Golf Honor Society
Tennis Clubs
VolleyBall Cheerleading
Soccer Other
X. OTHER INFORMATION
To avoid conflict of interest, list any local school board member or employee relative(s) in the school division and cite relationship.
Please provide any additional information you desire that will afford an additional understanding of your qualifications, such as your goals, objectives, philosophy, and other background factors that are of special interest.
ADDITIONAL REMARKS AND/OR EXPLANATIONS FROM SECTION VII GENERAL INFORMATION


In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating
on the basis of race, color, national origin, age, sex or disability. To file a complaint of discrimination,
write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410
or call (800) 795-3272 or (202) 720-6382 (TTY). USDA is an equal opportunity provider and employer.

© 2006 - 2013 Galax City Public Schools • 223 Long Street • Galax, Virginia 24333 • Phone: 276-236-2911 • Fax: 276-236-5776 • Email: info@gcps.k12.va.us

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