Dodge County Board of Education Rex Hodges, Interim Superintendent Post Office Box 1029 - 720 College Street Eastman, Georgia 31023-1029

Phone: (478) 374-3783 Fax: (478) 374-6697

(Please Type or Print)

POSITION(S) DESIRED____ __DATE_

______

Name Last First Middle Social Security Number

Present Address _ __ ( ,) Street Telephone

Permanent Address _ ___ ( )

Street Telephone

City State Zip

Birth Date---------- E-Mail Address (if available)_________________

MISSION STATEMENT FOR DODGE COUNTY SCHOOLS

The mission of the Dodge County School System is to provide all students the knowledge, skills, and values to succeed in life through quality educational programs and effective learning experiences both in school and in the community.

CERTIFICATION (List all areas in which you hold valid Georgia and/or out-of-state teaching certificates.

NOTE: Applicants holding a certificate from another state must obtain a Georgia Certificate in order to teach in Georgia Public Schools.)

AREA OF CERTIFICATION Issuing State Date Issued

Have you acquired tenure in Georgia? If yes, in what school district?

Date available for employment=----�----------------

If you are not employed full-time, are you interested in being placed on our Substitute List? __ Yes __No

Long-term __ Yes __No Short-term __ Yes __No

City State Zip

EDUCATIONAL BACKGROUND

School or Institution and Location Major/Minor Diplomas, Degrees Grade Point

Graduate Study

Graduate Study

EXPERIENCE

(Include dates for Military Service if any)

Name of School and Location DATES No.of NATURE OF WORK

From To Teachers in If grades, specify what grades and subjects:

School If high school, the subjects taught and any extracurricular work handled

Please list activities that you are qualified to supervise or coach:

If you have not been previously employed in a teaching position, please complete the following:

STUDENT OR PRACTICE TEACHING

STUDENT TEACHING REFERENCES: Please attach photocopies of letters of reference and or evaluations from college/university student supervisor and cooper­ ating teacher(s).

or Credits Earned Average (GPA)

High School

College/University

College/University

Grade or Subject Taught

Name and Address of School 1. College Supervisor 2. Cooperating Teacher

1.

2.

1.

2.

REFERENCES: These should be persons qualified to provide information concerning your ability to perform the duties of the position you seek. Please include superintendents and principals under whom you have taught.

NAME TELEPHONE NUMBER ADDRESS OCCUPATION

1.

2. --------------------------------------------------

3. --------------------- ----- ----------------------

OTHER QUALIFICATIONS: Summarize special job-related skills and qualifications acquired from employment or

other experiences (including U.S. military service) and/or state any additional information you feel may be helpful in

considering your application, i.e. honors, awards, activities, technology skills or professional development activities.

Background Information Have you ever been dismissed or asked to resign from any position? Yes No If yes, explain:__________________________________________________________________________________________________________________________________________________________________________________________ An answer of yes does not necessarily disqualify you from the position, but any failure to respond accurately and completely may result in disqualification or dismissal if discovered after employment. I hereby certify that all statements made in this application are true and complete to the best of my knowledge and authorize investigation of all statement herein recorded. I understand that any false statements or omissions of fact may subject me to disqualification or dismissal if discovered after employment. I understand I am required to furnish information and references to use in determining my qualifications. I understand that the District may conduct an investigation of my work and/or personal history and that it may verify all data given in my application for employment, related papers and/or oral interviews. I further understand that any and all references that I have provided to the District, either in writing or otherwise may be contacted. Your fingerprints will be used to check the criminal history records of the FBI. You have the opportunity to complete or challenge the accuracy of the information contained in the FBI identification record. The procedure for obtaining a change, correction or updating an FBI identification record is set forth in Title 28 Code of Federal Regulations 16.34. Procedures for obtaining a copy of the FBI criminal history record are set forth in 28 CFR 16.30-16.33 or go to FBI website at http://fbi.gov/about-us/cjis/background-checks. My signature below authorizes Dodge County Board of Education to conduct a background investigation and authorizes the release of information in connection with my application for employment. I authorize any previous employer and/or any other reference to release and fully disclose to any agent of the District any information such person may have concerning me, including information of a confidential or privileged nature, whether or not it is in their records. Further, I hold harmless any individual or employment agency for any information that he/she/it may provide in this investigation. I waive my right of access to any such information and without limitation hereby release Dodge County Board of Education and the reference source from any liability in connection with its release or use. A photocopy of this release form will be valid as an original thereof, even though the said photocopy does not contain my original signature.

Signature: Date:

Conviction Report

All applicants must complete this form. This information will be kept confidential and separate from your application.

As part of the application process, you are required to report any and all convictions or current charges for a crime, no matter when they may have occurred. A conviction will not automatically prevent you from being considered for hire – falsification of your application, by not reporting or inaccurately reporting, will prevent you from being considered for any employment in Dodge County Board of Education.

Have you ever been convicted of or have a current charge pending of any violation of the law? YesNo If yes, list the violation code number for each offense, including those for which you forfeited bail, were fined and/or jailed, or placed on probation. Include a complete and accurate explanation of the circumstance (you may submit an additional page if you need more space than provided below).

Violation Code Date ______

Disposition/Explanation: Violation Code Date ______

Disposition/Explanation: Violation Code Date ______

Disposition/Explanation: I certify that I have listed all my convictions and any current charges, except minor traffic offenses. I understand that my failure to complete this form, any omission of convictions and current charges, or misrepresentation of material facts will result in disqualification, or if discovered after employment, my dismissal from Dodge County Board of Education. Signature: _____________________________________________ Date:_________

ESSAY

We are interested in your ability to organize and express thoughts on a specific topic in a succinct manner. Please select one of the following topics and write an essay on an attached sheet.

1. The Most Important Qualities of an Outstanding Educator 2. My Philosophy of Student Discipline 3. The Importance of Continuing Professional Development and how I Plan to Incorporate it Throughout

My Career 4. Essential Elements of Instruction, Administration or Area of Certification 5. How Information Technology (i.e. computers, Internet) can be Integrated into the Instructional

Process and Curriculum

CERTIFICATION AND RELEASE AUTHORIZATION

I certify that all of the statements made by me are true, complete and correct to the best of my knowledge and belief, and are

made in good faith. I further certify that I am the sole author of the essay. I understand that any misrepresentation of

information shall be sufficient cause for: (1) rejecting my candidacy, (2) withdrawing of any offer of employment, or (3)

terminating my employment.

I hereby authorize any and all of my previous employers and/or supervisors to release any and all of my personnel records,

and to respond fully and completely to all questions that officials of the Dodge County Board of Education may ask regard­

ing my prior work history and performance. I will hold such previous employers and/or supervisors harmless of any and

all claims that I might otherwise have against them with regard to statements made to this school district. I further authorize

these officials to investigate my background, now or in the future, to verify the information provided and release from

liability all persons and/or entities supplying information regarding my background. However, I do not authorize the

production of medical records or other information which would actually identify a disability nor do I authorize inquiries

which would include information related to any medical condition or medical history. Further, I do not waive any rights

which I may have under state or federal law related to my right to challenge the disclosure of unlawful or inaccurate

information, whether by the school district or by entities or persons providing such information to the school district,

including any and all claims concerning allegations of employment discrimination because of race, color, sex, religion,

national origin, ancestry, age or disability.

___________________ _____________________ Date Signature of Candidate (in ink)

(must be original)

Georgia school districts shall not discriminate in their educational programs, activities or employment practices based on race, color,

national origin, sex, disability, age, religion, ancestry or any other legally protected classification. T his policy is in accordance with the

state and federal laws, including Title VI of the Civil Rights Act of 1964, Title IX of Education Amendments of 1972, Sections 503 and

504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and the Americans with Disabilities Act of 1990. Information

relative to special accommodation, grievance procedure, and title designated responsible official for compliance with Title VI, Title IX, and

Section 504 may be obtained by contacting the school district.

When hired, every Dodge County employee is required to have a criminal records check.

Checklist for Teacher's Application

Transcripts

---Teaching Certificates

Completed Reference Forms (3)

---GACE or PRAXIS Scores

Copies of Current Evaluation (if applicable)

---Resume

D

Dodge County Board of Education Request for Professional Reference

has applied for a position as a(n) ---------­ in the Dodge County School System. Your evaluation of the applicant will be a service to this office and to the applicant. Thank you for you tim!7 and assistance in this matter.

This evaluation form is confidential and will not be shown to the

candidate unless he/she has marked the non«>nfidential box and signed

tMform.

Superintenaem

Dodge County Schools

Non-Confidential Evaluation (Open to review by candidate)

Applicant's Signature Date

PROFESSIONAUSM

Seeks professional growth

Fulfills assignments according to policies

Maintains good ph}'Jlical and mental health

Contributes to total school program

Is regular in attendance

INSTRUCTION

Demonstrates knowledge and enthusiasm when teaching

Plans and organizes for effective instruction

Offers stimulating psychological and physical environment

Uses resources and methods appropriately for teaching and evaluation

Practices good communication skills

STUDENT MANAGEMENT

Maintains a positive, respectful and professional manner

Involves students in the learning process

Is consistent and fair in dealing with students

PERSONAL RELATIONSIIlPS

Accepts others

Exercises and respects proper authority

OVERALL EVALUATION

Your aquaintanc:e with this applicant has been as: --- employer friend relative instructor -- c:o-worker Date: From Would you employ applicant in such a position? Yes No Maybe

To

Why?---------------------------------------

Other Comments: -----------------------------------

Should we telephone you for additional information? Yes No

Signature Area Code/Phone Number

Position

Please return this form to: Dodge County Schools Office of the Superintendent

P.O. Box 1029 Eastman, Georgia 31023

Date

l 1 � r i I D

Dodge County Board of Education '

Request for Professional Reference

--------------- has applied for a position as a(n) ----------­ in the Dodge County School System. Your evaluation of the applicant will be a service to this office and to the applicant. Thank you for you tiin� and assistance in this ni;ttter.

This evaluation form is confidential and will not be shown to the candidate unless he/she has marked the non-confidential box and signed the form.

Superintenaem Dodge County Schools

Non-Confidential Evaluation (Open to review by candidate)

Applicant's Signature Date z : 5 o l J I� :::>

l8@SJ1ii!iWWlM�&t@iliff@:%frJf,tf$ PROFESSIONALISM

Seeks professional growth Fulfills assignments according to policies Maintains good phy.11ical and mental health Contributes to total school program Is regular in attendance

INSTRUCTION Demonstrates knowledge and enthusiasm when teaching Plans and organizes for effective instruction Offers stimulating psychological and physical environment Uses resources and methods appropriately for teaching and evaluation Practices good communication skills

STUDENT MANAGEMENT

Maintains a positive, respectful and professional manner

Involves students in the learning process

Is consistent and fair in dealing with students

PERSONAL RELATIONSHIPS

Accepts others

Exercises and respects proper authority

OVERALL EVALUATION

Your aquaintance with this applicant has been as:

_ employer friend relative instructor --- co-worker Date: From Would you employ applicant in such a position? Yes No __ Maybe

To

\.Vhy? --------------------------------------�

Other Comments: ------------------------------------------

Should we telephone you for additional information? Yes No

Signature Area Code/Phone Number

Position

Please return this form to: Dodge County Schools

Office of the Superintendent

P.O.

o o § ] !ii i

Box 1029 Eastman, Georgia 31023

Date

D

Dodge County Board of Education Request for Professional Reference

--------------- has applied for a position as a(n) ----------­ in the Dodge County School System. Your evaluation of the applicant will be a service to this office and to the applicant. Thank you for you timt? and assistance in this matter.

This evaluation form is confidential and will not be shown to the candidate unless he/she has marked the non-confidential box and signed the form.

Superintenaem Dodge County Schools

Non-Confidential Evaluation (Open to review by candidate)

Applicant's Signature Date

PROFESSIONALISM

Seeks professional growth

Fulfills assignments according to policies

Maintains good phy.sical and mental health

Contributes to total school program

ls regular in attendance

INSTRUCTION

Demonstrates knowledge and enthusiasm when t eaching

Plans and organizes for effective instruction

Offers stimulating psychological and physical environment

Uses resources and methods appropriately for teaching and evaluation

Practices good communication skills

STUDENT MANAGEMENT

Maintains a positive, respectful and professional manner

Involves students in the learning process

Is consistent and fair in dealing with students

PERSONAL RELATIONSHIPS

Accepts others

Exercises and respects proper authority

OVERALL EVALUATION

Your aquaintance with this applicant has been as: ___ employer friend relative instructor --- co-worker Date: From Would you employ applicant in such a position? Yes No Maybe

To

\.Vhy? --------------�------- --- -��--�-�-----�

Other Comments: ---------------------------------------

Should we telephone you for additional information? Yes No

Signature Area Code/Phone Number

Position

Please return this form to: Dodge County Schools

Office of the Superintendent P.O. Box 1029

Eastman, Georgia 31023

Date