ASHLAND-GREENWOOD PUBLIC SCHOOLS

1225 CLAY STREET

ASHLAND NEBRASKA 68003

APPLICATION FOR SUPERINTENDENT OF SCHOOLS

Name:Date:

LastFirstMiddle

Address:Email:

StreetCityStateZip

Telephone:

HomeBusinessCell

Present Position:School District:

Student EnrollmentNumber of Certified Staff:

Annual Budget:Present Salary:

CERTIFICATION

1.Do you hold a Nebraska Administrative Certificate with a Superintendent endorsement?

2.If not, are you eligible for the Superintendent certificate for this position?_____

SUMMARY OF EXPERIENCE (List in reverse chronological order, beginning with the position held before the current position)

Dates: from - to / Position/Institution/
Location / Supervisor’s Name and Title / Supervisor’s phone:
Home, business, cell

EDUCATIONAL RECORD (List chronologically.)

Name and Location of Institution Attended / Dates of Attendance (Mo/Yr) From …To / Degree / Major(s) / Minor(s)
-
-
-
-
-

REFERENCES

Please provide the School District the names of four references who can provide information about your experience and qualifications in detail.

NAME / POSITION/RELATIONSHIP / ADDRESS / PHONE NUMBER
Home:
Business:
Cell:
Home:
Business:
Cell:
Home:
Business:
Cell:
Home:
Business:
Cell:

PERSONAL DISCLOSURE

Respond to EACH item. If there is no response to any item or if upon request you fail to complete authorization for a background check, you will be removed from consideration. Information provided in this disclosure will not automatically bar you from employment but will be considered in view of all relevant circumstances

Are you a U.S. citizen?Yes _____No _____ If not, are you eligible to work in the United States? Yes ___No ___

.

Please attach a detailed explanation to any item for which your answer is ‘yes’.

Have you ever been terminated from any position, or resigned at the request of your employer?Yes ___No ___

Have you ever had a certificate, permit or license revoked, terminated, suspended or received a private or public reprimand or admonishment from the Nebraska Department of Education or other licensing agency or been subject to a judicial restraining or contempt order or do you have any current professional practice complaints pending with the Nebraska Department of Education or other licensing agency? Yes ___ No ___

Have you ever received a ticket, been charged with an offense, or been arrested for anything other than a minor traffic violation? (If you are unsure if a ticket, a charge or an arrest was a minor traffic violation, answer "Yes") Yes ___ No ___

Are you currently involved in any lawsuit, or anticipate involvement in any lawsuit?Yes ___No ___

Have you ever filed a complaint or grievance against any employer?Yes ___No ___

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

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, and I understand that any omission, falsely answered statements made by me on this application, or on any supplement to this employment application will be sufficient grounds for failure to employ or for my discharge should I become employed with the school district.

Date ______Signature of Applicant ______

Application requirements:

  1. Letter of application, including reasons for interest in the position.
  2. A signed copy of this application form.
  3. Resume.
  4. Names, titles, and phone numbers (home, business, and cell) of four references who can be contacted.
  5. Optional – letters of recommendation.

Please direct all inquiries, applications, and supporting materials to Baker & Rastovski School Services, email address: DO NOT CONTACT THE DISTRICT OR BOARD MEMBERS DIRECTLY.

Phone: Roy Baker, 402-470-1321 or Ed Rastovski, 402-430-5837

APPLICATION DEADLINE: February 4, 2011.

Neither the Ashland-Greenwood Public Schools nor Baker & Rastovski School Services discriminate on the basis of religion,sex, race, national origin, marital status, age, or disability with regards to employment, benefits, programs, or activities.