SOUTH NEWTON SCHOOL CORPORATION

13232 S. 50 E.

Kentland, IN47951

219-474-5184

Fax: 219-474-6966

APPLICATION

FOR

ADMINISTRATIVE POSITION

The South Newton School Corporation does not discriminate in hiring or employment on the basis of race, color, sex, age, handicap, religion, or national origin. No questions on this form are intended to secure information to be used for such discrimination. This application will be given every consideration, but its receipt does not imply the applicant will be interviewed or employed. All applications will be acknowledged in writing to the address indicated by the applicant, and each application will be treated confidentially. This application, and all supporting documents, must be postmarked by the date listed on the position posting. Applicants are asked not to contact the Superintendent or members of the Board except as requested to do so.

Mail completed application to:

Todd Rudnick, Superintendent

South Newton SchoolCorporation

13232 S. 50 E.

Kentland, Indiana47951

BACKGROUND INFORMATION

(Please type or print)

Name ______

LastFirst Middle

______

Present PositionBusiness Phone Home Phone

Business Address: Home Address

______

______

E-mail Address ______

Present Salary ______Expected Salary ______

Length/Ending Date of Current Contract ______

Do you hold, or are you eligible to obtain, a valid Indiana Administrator’s License for the position you are seeking? _____Yes _____ No

What other valid Indiana certificates do you hold?

Where will your confidential placement file be forwarded from? ______

Name of Institution

References: Please list the names of five (5) persons who know your professional background and qualifications. These may include school board members, university professors, members of the community, Administrators, etc.

______

NameAddressOffice PhoneHome Phone

______

NameAddressOffice PhoneHome Phone

______

NameAddressOffice PhoneHome Phone

______

NameAddressOffice PhoneHome Phone

______

NameAddressOffice PhoneHome Phone

I give my authorization for you to contact the above references of any other references deemed necessary to ascertain the merits of my candidacy for this position and to hold them and the consultants harmless for providing and/or utilizing any information requested and/or provided.

______

SignedDate

EDUCATIONAL TRAINING

Undergraduate:

InstitutionDate Attended Major/Minor Degree & Date

Graduate:

InstitutionDate Attended Major/Minor Degree & Date

Additional Educational Preparation (include specialized seminars, workshops, etc.):

InstitutionDate Attended Major/Minor Degree & Date

MILITARY EXPERIENCE

Branch Highest Rank Date of Entry Date of Separation

PROFESSIONAL EXPERIENCE AND/OR EMPLOYMENT HISTORY:

(Please list most recent first.)

PositionOrganizationFromToResponsibilities (Briefly)

PROFESSIONAL ORGANIZATIONS:

(List the organizations in which you have been most active and indicate offices held, personal contributions, or other responsibilities.)

Organization Leadership Role Remarks/Responsibilities

COMMUNITY LEADERSHIP ACTIVITIES:

(list the activities in which you have been most active recently and indicate offices held, personal contributions, or other responsibilities.)

Activity Leadership Role Community Impact

COMMUNITY MEMBERSHIPS AND AFFILIATIONS: (Specify Community)

Organizations Leadership RoleRemarks

HONORS AND DISTINCTIONS:

(List degrees, honors, awards, commendations, elective or appointive offices held, or other distinctions received.)

DateHonor, Degree, Etc. (Include source, institution, etc. Comment, if desired)

APPLICATION QUESTIONS

(Please respond to each question on a separate paper)

  1. Describe your educational and management philosophies.
  2. Describe the talents, skills and special qualifications you possess that will make you a successful administrator in the South Newton School Corporation.
  3. In what areas do you feel least qualified for the position you are seeking?
  4. What are your primary sources for information regarding educational practices, change, and innovation?
  5. Briefly describe your three most significant professional accomplishments.

Include your position, where, and when each accomplishment took place.

6. Identify any unique qualifications and/or experiences that may distinguish you from

other candidates.

OTHER QUESTIONS

___ Yes ___ No 1. Are you presently being investigated or under a procedure

to consider your discharge for misconduct by your

present employer?

___ Yes ___ No 2.Have you ever been reprimanded, disciplined,

discharged, or asked to resign from a prior position?

___ Yes ___ No 3.Have you ever resigned from a prior position without

being asked, but under circumstances involving your

employer’s investigation of sexual misconduct with another

person, mishandling of funds, or criminal conduct?

___ Yes ___ No 4.Have you ever been charged with or investigated for

physical sexual abuse of another person?

___ Yes ___ No 5.Have you ever been charged with, pleaded guilty or “no

contest” to, or been convicted of, any crime involving

sexual abuse of any person or any other crime of moral

turpitude?

___ Yes ___ No 6.Have you ever been convicted of a misdemeanor and/or

felony or ever entered a plea of guilty or a plea of “no

contest”, or has any court ever deferred further

proceedings without entering a finding of guilty or place

you on probation for a crime?

___ Yes ___ No 7.Have you missed over ten (10) days of work in the last

two (2) years?

___ Yes ___ No 8.Have you had a serious illness in the last five (5) years?

___ Yes ___ No 9.Do you have any physical limitations, diseases, or

ailments which might interfere with or be aggravated by

your work?

If you have answered yes to any of the first nine (9) questions, please explain on a separate paper including the date of the incident, charge, any court action taken, the offense in question, and the address of any court involved, or the nature of the illness injury, the date incurred and the physician involved.

I understand that any false or misleading information provided in this application shall be sufficient grounds to refuse employment, and/or for contract termination.

Signature ______Date ______

AUTHORIZATION AND RELEASE

I authorize personnel from South Newton School Corporation to check my employment history, including a “limited criminal history” possessed by any private or public employer or local, state or federal agency. I authorize these private or public employers or local, state or federal agencies to provide the South Newton School Corporation any information they may request concerning the matters described herein, and I will cooperate to the extent necessary to obtain the release of this information.

I hereby certify that the information found within this application has been provided voluntarily, and I waive any right to assert discrimination on the basis of that which has been divulged. I also affirm that the information on this application is accurate to the best of my knowledge, and I understand that my application will be retained in current files for a period of one year.

I expressly waive in connection with any request for, or provision of such information, any claims or accuses of action including, without limitation, defamation, infliction or emotional distress, invasion of privacy, or interference with contractual relations that I might otherwise have against the school district, its officials, employees, trustees or agents, or against any provider of any information.

I have read this authorization and release of all claims, and I expressly agree to the terms set out herein.

Signature ______Date ______