ࡱ                >  	                                          5@	                  bjbj22                  	 `  X  X                        )                                              2      2  2      2      2      2      2  D           v      :2      :2      :2      :2  <   v2     v      |     ^3      ^3      ^3      ^3      ^3      a      a      a                                           $   2  R    |   !                     2      a                      t  B  a      a      a      !              2      2      ^3              ^3  @  6     a      a      a      a      2    ^3      2      ^3                    a                                                      a            a  &   a                    "	    2                                                                    ^3      R3     f&o        :2      a                      T  L  0   |                   a                           v      v      2      2      2      2                                     2                            a                                                      a      a      a      !      !      v      v  %  :2              a      v      v      :2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         NAME ADDRESS	TELEPHONE NUMBER	Do you have Kansas Certification in the required area(s)?	 High School Undergraduate Graduate Undergraduate Major	Graduate Major	 1.	2.	3.	Yes	Yes	Yes	 Yes	GALENA UNIFIED SCHOOL DISTRICT NO. 499EMPLOYMENT APPLICATIONCERTIFIED PERSONNELWe consider applicants for all positions without regard torace, color, religion, sex, national origin, age, marital orveteran status, the presence of a non-job-related medicalcondition or handicap, or any other legally protected status.PLEASE PRINT OR TYPEPOSITION DESIREDDATE OF APPLICATIONLastFirstMiddleNumber & StreetCity/StateZip CodeIf your credentials are available at a college placement office, please indicate how tosecure a copy of them.EDUCATIONName of SchoolDates AttendedLocationDate ofDiploma or DegreeFromToGraduationMinorMinorList teaching fields in order of preferenceTEACHING EXPERIENCEFields or GradesWhereDatesSuperintendentFromToList other work experienceList the extracurricular activities in which you participated in high schoolIn collegeList any honors or special recognition which you received in high school or collegeList any other information concerning yourself which in your judgment might behelpful as we consider your applicationList professional, trade, business or civic activities and offices held.You may exclude memberships which would reveal sex, race, religion, national origin, age.REFERENCESGive name, address and telephone number of three references who are not related to you and are notprevious employers.Have you ever had any job- related training in the United States Military?NoIf yes, please describeAre you physically or otherwise unable to perform the duties of the job for which you are applying?NoDo you have any relatives who work for the district or who serve on the Board of Education?NoIf yes, please state their names and your relationship.U.S.D. # 499  COMMITTED TO EXCELLENCEMoral turpitude is an act of baseness, vileness or depravity in the private and social duties.to the accepted rule of right and duty between persons, including, but not limited to theft,which a person owes another member of society or society in general and which is contraryattempted theft, murder, rape, swindling and indecency with a minor. Have you ever beenconvicted of or plead guilty or nolo contender to a felony or any offense involving moralturpitude?NoIf yes, please explain:(Conviction of a crime is not an automatic bar to employment.)Why are you seeking to change positions or why did you leave your last position?APPLICANT JOB APPLICATION ACKNOWLEDGMENTS1. I certify that all the information provided by me in this application is true andcomplete. I understand that any misstatement, falsification, or omission ofinformation is grounds of refusal to hire, or if I am hired and the same is discoveredthereafter, termination.2. I authorize any of the persons or organizations referenced in this application to giveyou any and all information concerning my previous employment, education, or anyother information, personal or otherwise, with regard to any of the subjects coveredby this application, and I release all such parties from all liability for any damagesthat may result from furnishing such information to you. I authorize anybackground checks by any third party.3. I authorize you to request, receive, and verify all information given on thisapplication and release you from all damages that may result from your doing so.4. I authorize you to conduct a criminal background investigation using any and allmethods necessary to successfully complete such investigation and I release youfrom all liability for any damages that may result from your doing so.DateSignatureGALENA UNIFIED SCHOOL DISTRICT NO. 499 IS AN EQUAL OPPORTUNITY EMPLOYER.GALENA UNIFIED SCHOOL DISTRICT NO. 499702 EAST 7 TH STREETGALENA, KS 66739(620) 783 -4499 Ext. 1 1 00Brian D. SmithSuperintendent                                                                                                                                                                                                                                                                                                                  	            (  )  *  +  d  e  f  g  h  i  x                 	  	  	  	  	  	  	  	  	  	  	  	  	   	  !	  "	  ?	  C	  D	  E	  F	  G	  H	  I	  L	  N	  Պ  h a B*CJ RHY aJ ph    h a B*CJ RHl aJ ph    h a B*CJ RHk aJ ph    h a 5B*RHa \ph    h a B*RHg ph    h a B*RHc ph    j    h a UmH nH u h a 5B*RH` \ph    h a B*CJ aJ ph    h a 6         
                                                                    p            Y                                                                       d  &+D8/ 7$ 8$     9"~&&d +D!/ 7$ 8$ P      `     F6&&d +D!/ 7$ 8$ P      `   d  &+D3/ 7$ 8$     t&&d +D!/ 7$ 8$ P      `     tr&&d +D!/ 7$ 8$ P      `    1$ 7$ 8$ H$     	                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        +  g  i  y  z  |                                                                z            z            z            a                                                   d  $P	 &+D3/ 7$ 8$ H$ If     7$ 8$ H$    d  n. &+D/ 7$ 8$ `     d  4( &+DA/ 7$ 8$    v
 d  $ &+D</ 7$ 8$     9"~&&d +D!/ 7$ 8$ P      `     F6&&d +D!/ 7$ 8$ P      `  	                                                                                R                                                          kd    $$If   l ֈ   F
J                          	                                                                                             4 
l al   dx  $P	 &+D3/ 7$ 8$ H$ If    	                                                  R            9                                  d%  $P	 &+D3/ 7$ 8$ H$ If      kd"  $$If   l ֈ   F
J                          	                                                                                             4 
l al   dx  $P	 &+D3/ 7$ 8$ H$ If                                                                  R            9                      d  $P	 &+D3/ 7$ 8$ H$ If      kdD  $$If   l ֈ   F
J                          	                                                                                             4 
l al   dx  $P	 &+D3/ 7$ 8$ H$ If                                                                              R                                                                         kdf  $$If   l ֈ   F
J                          	                                                                                             4 
l al   d  $P	 &+D3/ 7$ 8$ H$ If                                                                                                                                                                                                                                                                                                                                                                                                            d<  $P	 &+D3/ 7$ 8$ H$ If     d  $P	 &+D3/ 7$ 8$ H$ If                    k            R            R            R            R            R            R                                                       d  $P	 &+D3/ 7$ 8$ H$ If      kd  $$If   l rֈ   F
J                          	                                                                                             4 
l al                k            R            R            R            R            R                                                                        d  $ &+D
/ 7$ 8$ H$ If      kd  $$If   l ֈ   F
J                          	                                                                                             4 
l al                ~            e            e            e            e            e                                                                                                              d  $ &+D
/ 7$ 8$ H$ If      kd  $$If   l r   r      	               6                                                                             4 
l al                ~            e            e            e            e            e                                                                                                              d  $ &+D
/ 7$ 8$ H$ If      kd  $$If   l r   r      	               6                                                                             4 
l al                ~            e            e            e            e            e                                                                                                              d  $ &+D
/ 7$ 8$ H$ If      kd  $$If   l r   r      	               6                                                                             4 
l al                ~            e            e            e            e            e                                                                                                              d  $ &+D
/ 7$ 8$ H$ If      kd	  $$If   l r   r      	               6                                                                             4 
l al          ~            x            J                                                                                                          -   h&$d &d 'd +D/ 7$ 8$ N      P      Q      `   7$ 8$ H$    kd
  $$If   l r   r      	               6                                                                             4 
l al        	  	  	                                      g            P                                                                                       d  8&+D4/ 7$ 8$     w
&&d +D!/ 7$ 8$ P      `    { d  w=&+D*/ 7$ 8$  -   Io	&$d %d &d +D/ 7$ 8$ N      O      P      ` 6   w&$d %d &d 'd +D/ 7$ 8$ N      O      P      Q      `  	  	  	  	  	  	  	                                      g            S            ?                                   &+D / 7$ 8$ `    &+D / 7$ 8$ ` 6   D	&$d %d &d 'd +D/ 7$ 8$ N      O      P      Q      `  -   &$d &d 'd +D/ 7$ 8$ N      P      Q      `   d   &+D3/ 7$ 8$ `    &&d +D!/ 7$ 8$ P      `  	  	  	   	  "	  @	  A	  C	  E	  G	                                                                                      o            X                                 %dB   &+D/ 7$ 8$ `%   dB  N &+D/ 7$ 8$ `   7$ 8$ H$   [dB  5 &+D/ 7$ 8$ `[   d  +1 &+D</ 7$ 8$ `    dB  + &+D/ 7$ 8$ `  -   &$d %d &d +D/ 7$ 8$ N      O      P      `  	G	  I	  Q	  U	  Y	  _	  `	  b	                                                              o            X                                                                   vdB  & &+D/ 7$ 8$ `v    $&&d +D!/ 7$ 8$ P      `     d  $&+D%/ 7$ 8$      dB   &+D/ 7$ 8$      d=   &+D/ 7$ 8$      d   &+D/ 7$ 8$    dB  i &+D/ 7$ 8$ `  N	  O	  P	  Q	  S	  U	  W	  Y	  \	  ]	  ^	  `	  a	  b	  e	  f	  g	  i	  l	  m	  n	  p	  q	  r	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
  
  
  
  	        0  2  6  8  󵨠h a 5B*RH` \ph    h a 5>*B*RHa \ph     h a B*ph    h a 5B*RHa \ph    h a B*RHa ph    h a B*RHX ph    h a B*CJ RH_ aJ ph    h a B*CJ RH\ aJ ph    j    h a UmH nH u h a B*CJ aJ ph     4b	  h	  i	  o	  p	  r	  	  	  	  	                                                              z            z            z            c                                                         d  ;&+D./ 7$ 8$   7$ 8$ H$    dB  32 &+D/ 7$ 8$ `     /&&d +D!/ 7$ 8$ P      `     d  /&+D%/ 7$ 8$     ,&&d +D!/ 7$ 8$ P      `     d  ,&+D%/ 7$ 8$  		  	  	  	  	  	  	  	  	  	  	  	                                                              k            e            e            e            e            e                         7$ 8$ H$     ..&&d +D!/ 7$ 8$ P      `     .;&&d +D!/ 7$ 8$ P      `    d  & &+DF/ 7$ 8$ `   d  Q &+D/ 7$ 8$   d  Q &+D/ 7$ 8$     ;`&&d +D!/ 7$ 8$ P      `  	  
  
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  |
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                    	  d  7$ 8$ H$   d   7$ 8$ H$ 	  d  7$ 8$ H$   d   7$ 8$ H$   7$ 8$ H$                                                                                                                                                                                                                                                                                                                                                                                                        h a B*CJ aJ ph    h a  h a 5B*RH` \ph    h a B*ph    h a 5B*RH[ \ph     # 0 P . A!h"h#h$h%  # 0 P . A!h"h#h$h%  # 0 P . A!h"h#h$h%  # 0 P . A!h"h#h$h%                                                                                                                                                                                                                                                                                                                                                                               $$If   l !v h5 55555	#v #v#v#v#v#v	:V l      5 55555	/ /      /       /       /       /      /4    al  $$If   l !v h5 55555	#v #v#v#v#v#v	:V l      5 55555	/ /      /       /       /       /      /4    al  $$If   l !v h5 55555	#v #v#v#v#v#v	:V l      5 55555	/ /      /       /       /       /      /4    al  $$If   l !v h5 55555	#v #v#v#v#v#v	:V l      5 55555	/ /      /       /       /       /      /4    al  $$If   l !v h5 55555	#v #v#v#v#v#v	:V l r     5 55555	/ /      /       /       /       /      /4    al  $$If   l !v h5 55555	#v #v#v#v#v#v	:V l      5 55555	/ /      /       /       /       /      /4    al  $$If   l !v h5 5	5556#v #v	#v#v6:V l      5 5	556/ /      /       /       /       /      /4    al  $$If   l !v h5 5	5556#v #v	#v#v6:V l      5 5	556/ /      /       /       /       /      /4    al  $$If   l !v h5 5	5556#v #v	#v#v6:V l      5 5	556/ /      /       /       /       /      /4    al  $$If   l !v h5 5	5556#v #v	#v#v6:V l      5 5	556/ /      /       /       /       /      /4    al  $$If   l !v h5 5	5556#v #v	#v#v6:V l      5 5	556/ /      /       /       /       /      /4    al                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              @  @ @           N o r m a l       CJ _HaJ mH	sH	tH	                  D A@ D          D e f a u l t   P a r a g r a p h   F o n t     R i@ R          T a b l e   N o r m a l      4 
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  
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      X  Y          &  '  ~            E      :  ;  a  b          Z  [                M  N  u                    0                    M90                   M90                   M90                   M90                   M90                   M90                   M90                   M90                   M90                   M90                   M90                   M90                    M90                        0                        0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                        0                       0                       0                       0             q          0             q          0             q          0             q          0             q          0                       0                       0             q          0             q          0                       0             q          0             q          0             q          0                   M90                        0                        0                       0             q          0             q          0             q          0             q          0             q          0             q          0             q          0             q          0             q          0             q          0             q          0             q          0             q          0                    M90                        0                        0                       0             q          0             q          0             q          0             q          0             q          0             q          0                        0                       0                   M90                    M90             $
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 ,Kg    0                    M90Q             $
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           i  t     4  %    C!    j    5          j    6    	      j    7      #    j    8    K      j    9    e      j    :    e  $    j    ;  	        j    <  6        j    =  ="    $    j    >  C       K"  j    ?  6       ."  j    @  8"     %  ."  j    A    m+  M'  -  j        j  #  )  j@    B  {    >    t     C      9    t                  t     D     y     t                }  t                  t                }  t     E      [    j    F          j    G       {    j    H  y    S    j    I      Z    j    J  h    %    j    K     ~    	  j    L    ~    	  j    M  U  ~    	  j    N  S    h    j    O  -  U  B  u  j    P      2    j    Q        !  j    R      0    j    S          j    T          j    U  A"    ?'    j    V          j    W          j    X    +  }  ;,  j    Y    n0    1  j    Z    5  	  7  j      k      v  j@      k  u    W	  j@        u    W	  j@          #  W	  j@      J        j@      J    f    j@    	  e        j@               }  t                ;  t     "           ;  t     [            t     \            t     ]            t     ^            t     _          t     &           }  t     `          t     a          t     )           ;  t     b      e!    j    c    
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  	           F   Microsoft Word Document 
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