Champions for Children
Champions for Children

 

 

Bellevue Public Schools
Telephone: (402)-293-4032/(800)-776-5204 Fax:(402)-293-5002
www.BellevuePublicSchools.org
An Equal Opportunity Employer
Professional Application

 


Personal Information (Required)
*Required

Name
  Last Name* First Name* Middle Initial
   
E-mail Address  
   
Present Address Home Phone:
  Work Phone:
  City State Zip  
   
Permanent Address Home Phone:
  Work Phone:
  City State Zip  
 
What Nebraska Certificate do you now hold?  
Type: Expiration Date:
Endorsement(s)

If no Nebraska Certificate is now held, select the area(s) of preparation.
Art Music Reading Elementary
Business English/Language Arts Foreign Language Physical Education
Family & Consumer Science Industrial Arts Mathematics Science
Social Studies JROTC Guidance/Counseling School Psychologist
School Nurse Media Specialist Administrator (Specify)
Specify other endorsements
 Special Education (specify)
Others:
   
EECIA test score or NCLB HQ status
   
If you have worked for the Bellevue Public Schools
under a different name , please give name.
 
Are you a citizen of the United States of America ? Yes No  
General Health  
 
POSITION PREFERENCE
Teaching Positions
Grade Levels Subject Area - 1st Preference Subject Area - 2nd Preference
     
Administrative Positions


EDUCATIONAL PREPARATION PRIOR TO BEGINNING TEACHING
School
Name of School
Location        
Elementary
Specialization or Nature
of Course Completed
College or University Level
High School
     
Dates Attended
Major Minor
Date Graduated
 Degree
College or
University

Scholastic Honors


Select scholastic average of undergraduate college work:
A A- B B- C C-

EDUCATIONAL PREPARATION AFTER BEGINNING TEACHING
College or University Location Dates attended Specialization or Nature of Course Followed Date Graduated Degree
Scholastic Honors

A transcript of all college work is required.

EDUCATIONAL EXPERIENCE Includes practice teaching. List most recent experience first.
Dates Name of School Location Specific Nature of Position No. Years Taught Annual Salary

OTHER PROFESSIONAL EXPERIENCE (Educational travel, lecturing, study, publications, organizations)
Dates Nature of Experience


UNITED STATES ARMED SERVICE RECORD
Dates Branch of Service
Total Months in Service Honorable Discharge?

INTERESTS AND HOBBIES List any interests or hobbies you may have outside the professional field.


Check any of the following activities which you can sponsor or co-sponsor:
Academic:

Band Choral Group Drama School Newspaper
Speech/Debate Yearbook

Athletics:
Athletic Trainer Baseball ( Head/ Asst) Basketball ( Head/ Asst) Cheerleading ( Head/ Asst)
Cross Country ( Head/ Asst) Football ( Head/ Asst) Golf (Head Coach Only) Soccer ( Head/ Asst)
Softball ( Head/ Asst) Swimming ( Head/ Asst) Tennis ( Head/ Asst) Track ( Head/ Asst)
Volleyball ( Head/ Asst) Wrestling ( Head/ Asst) Others
Others:


List any activities in which you engaged which may have prepared you to
direct any of the above checked activities:


List languages other than English you speak fluently:


List all the elected positions you have held as a student or in civic and professional life:


Indicate briefly what professional or general magazines and book reading you have done in the past six months:


GENERAL INFORMATION
Are you now or have you ever been a member of any party organization, political or otherwise,
that now or has ever advocated the overthrow of the Government of the United States
or the State of Nebraska by force or violence or unlawful means?
Yes No If you answered "Yes", please list the party or organization.

Have you ever been convicted of a felony or a misdemeanor charge involving moral turpitude or controlled substances?

Yes No If your answer is "Yes", please give details:
If "Yes" to the above, have you successfully completed a formal rehabilitation program since the date of your last conviction?
 Yes No If your answer is "Yes", please give the name of the center:
Have you ever been a party to a civil settlement, award, or agreement of any kind that involved an allegation concerning sexual conduct? Yes No If "Yes", please explain:
Have you ever had a teaching license revoked, suspended or denied? Yes No If "Yes", please explain:
Is disciplinary action of your license or any criminal charge pending in any state? Yes No If "Yes", please explain:

OTHER WORK EXPERIENCE (Business, trades, summer occupations, church work, social services, scouting, recreation, etc.)
Dates Firm or Institution Nature of Work No. of Months


References
(Give the names of those who have closely observed you work as a teacher or employee or as a student.)
Indicate with the checkbox any references which are included in your credentials.
  Name Official Position Present Address Telephone
Present Superintendent
Present Principal
         
Agency


GENERAL
(If you wish, give any additional information which you think might be of value
in considering you for a position in the Bellevue Public Schools.)


PRE-EMPLOYMENT INFORMATION
The policy of the Bellevue Public Schools. is to provide equal opportunity for all employees and for all persons seeking employment in our system" to prohibit discrimination because of race, color, religion, national origin, sex, age, physical or mental handicap, marital status, political affiliation and through affirmative action to promote the full realization of equal opportunity. Employment practices will demonstrate full adherence to the letter and intent of federal and state government policy guaranteeing equal employment opportunity for all persons.
The information on this form is needed for equal opportunity record keeping, and will be kept in a confidential file separate from the atttached
Pre-Employment Information Form

Position(s) Applied for Date

Name  
  Last First Middle  
         
Address
  Street City State
Zip Code
         
Birthdate Age Sex Male   Female  
         
Marital Status Single Married Widowed Divorced  
   
  Race/Ethnic Group      
White      
Black      
American Indian/Alaskan Native    
Asian/Pacific Islander    
Hispanic (Including person of Mexican, Puerto Rican, Cuban, Central or South American, or Spanish origin or culture regardless of race  
If none of the above categories seems appropriate, please indicate your background  
   
     
  Are you a citizen of the United States of America? Yes No  
     
  Do you have any handicapping conditions which may affect your ability to perform the duties required by the position for which you are applying? Yes No  
  If "Yes", please explain:
 
     


BACKGROUND CHECK

RELEASE AUTHORIZATION

In connection with my application for employment, I understand that an investigative consumer report may be requested that will include information as to my character, work habits, performance and experience,
along with reason for termination of past employment. I understand that as directed by company policy and consistent with the job described, you may be requesting information from public and private sources about my:
worker’s compensation injuries, driving record, court record, education, credentials, credit and references.
Medical and worker’s compensation information will only be requested in compliance with the Federal Americans with Disabilities Act (ADA) and/or any other applicable state laws. According to the Fair Credit Reporting Act, I am entitled to know if employment is denied because of information obtained by my prospective employer from a consumer-reporting agency. If so, I will be notified and given the name and address of the agency or the source, which provided the information. I acknowledge that facsimile
(FAX), photographic copy or email shall be as valid as the original.

I hereby authorize, without reservation, any law enforcement agency, institution, information service bureau, school, employer, reference or insurance company contacted by Jasa Investigative Services, Inc. or its agent, to furnish the information described above. I understand that in the event a negative hiring decision is made based upon the results of my background check, a report will be furnished to me upon my request.

The following information is required by law enforcement agencies and other entities for positive identification purposes when checking public records. It is confidential and will not be used for any other purposes. I
hereby release the employer and agents and all persons, agencies and entities providing information or reports about me from any and all liability arising out of the request for or release of any of the above mentioned information or reports.

I hereby release from liability any references named on this appication or included in my credentials file for having provided district representatives further information about my qualifications for employment with the Bellevue Public Schools.

I believe all this information I have provided onthis application ins correct, and I understand any false information may be considered cause for my termination.
I have read and accept this release authorization
I DO NOT ACCEPT the conditions of this application.

Last Name First Middle (required)
     
Other LEGAL names you have used
 
Home Address
     
City State Zip
     
Other address if less than 7 years at home address:
     
City State Zip