P.O. Box 960/18 Government Center Lane AUGUSTA COUNTY PUBLIC SCHOOLS

Verona, VA 24482 APPLICATION FOR

Phone: (540) 245-5100 / SUBSTITUTE TEACHER Date:

Fax: (540) 245-5115

APPLICATION OF: / Social Security Number:
(PLEASE PRINT) / (Give name as it appears on Social Security Card)
Present Address: / Phone #
City / State / Zip / Home:
Permanent Address: / Cell:
City / State / Zip / Work:
Please indicate school(s) that you would like to be considered for substituting:
Type of Virginia Certificate and Endorsements / Date Issued: / Expiration Date:

Are you related to the Superintendent or an Augusta County School Board Member? YES NO

NAME AND LOCATION OF SCHOOL
Including High School, College, Graduate Work and Summer in Order Taken / DATES OF ATTENDANCE
FROM TO / DIPLOMA, DEGREE
OR CERTIFICATE / MAJOR AND MINOR COURSES OR SPECIALIZATION

TEACHING EXPERIENCE(Include Practice Teaching – Aide Experience etc.)

NAME AND ADDRESS OR SCHOOL / DATES / GRADES OR SUBJECTS
TAUGHT / PRINCIPAL / SUPERINTENDENTOF
SCHOOLS

OTHER EXPERIENCE WORKING WITH CHILDREN OR YOUTH

NAME AND ADDRESS OF SCHOOL / DATES / GRADES OR SUBJECTS
TAUGHT / PRINCIPAL / SUPERINTENDENTOF
SCHOOLS
PERSONAL DATA
Name / Male / Female / Total Teaching Experience:
Present Position: / Have you resigned your present position?
Why are you leaving?
Present Salary? / When can you begin work?

Have you ever been discharged or requested to resign from a position? YES NO

Have you ever been convicted of a felony or any offense involving the sexual molestation, physical, or sexual abuse

or rape of a child? YES NO

Have you ever been convicted of a crime of moral turpitude? YES NO

Have you ever been the subject of a founded case of child abuse and neglect? YES NO

If the answer to any of the above questions is “YES”, please give below a full explanation including places and dates.

REFERENCES
1. Name: / Address: / Occupation:
2. Name: / Address: / Occupation:
3. Name: / Address: / Occupation:

REMARKS: (Any other personal data, which you feel, would be pertinent to this application.)

I hereby authorize the Augusta County School Division to investigate past employment including references.

Signed: / Date: