Martin County Schools

1) Date of Application

2) Name

3) Address

4) Date of Birth

5) Phone Number

6) Employment Type

Teacher

Administrator

Other

7) Other (optional)

If Other please list

8) Position

9) Certification

10) Work Experience ( Last Three Employers)

Place, Dates Inclusive, No. of Months, Type of Position, Reason for leaving

11) References: Minimum of Three

Name, Address, Title, Phone, Releated

12) Official Transcript, Certification, Support Documents (optional)

Attach Documents

Max 10 files | 200 MB limit

This application is kept on file for the current school year.

The Martin County Board of Education is an equal opportunity employer. The MC BOE does not discriminate on the basis of race, color, national origin, sex, disability or age in it's programs and activities.

*State law requires a KSP and FBI criminal background check as a condition of employment*

Character And Fitness

13) Name

14) Address

(Street, City, State, Zip Code)

15) Telephone number

Read all Questions below and answer "Yes" or "No"

Answer each question by circling "Yes" or "No." If you answer yes to any questions, you must submit a full explanation.

Questions

If you have ever held, or currently hold a professional certificate, license, credential, or other document issued to you by another jurisdiction(other than KY) within the United States or abroad, enclose a copy of the certificate(s) or Provide the Following on the next section.

State or Jurisdiction, Certificate Number, Type, Issue Date, Expiration date.

16) State or Jurisdiction, Certificate Number, Type, Issue Date, Expiration date. (optional)

State or Jurisdiction, Certificate Number, Type, Issue Date, Expiration date.

17) 1. Have you ever had a professional certificate, license, credential, or any document issued to you for practice denied, suspended, revoked or voluntarily suspended.

Yes

No

18) 2. Are you currently being reviewed or investigated for purpose of such action as stated in #1 or is such action pending.

Yes

No

19) 3. Have you ever been dismissed, resigned, or asked to resign/retire or discharged from any professional position or military service for immorality, incompetence, willful neglect of duty, misconduct.

Yes

No

20) 4. Is any such action as stated in #3 pending

Yes

No

21) 5. Have you ever been convicted of a felony or misdemeanor, been found guilty or entered a plea of no contest, even adjudication was withheld, in Kentucky or any other state

Yes

No

22) 6. If you have indicated yes to any items #1 through #6, has that conviction been reviewed by the Educational Standards Board? Date of Review (optional)

23) If yes was answered to any of the above write explanation below. (optional)

Affirm

I affirm and declare that all information given to me on this form is true, and correct and complete to the best of my knowledge. I understand that and misrepresentation of facts, by omission or addition my result in cancellation of employment contract.

I declare that I understand the standard for personal and professional conduct expected of a school district employee in Kentucky. I further certify that I have read and examined the CODE OF ETHICS applicable to school personnel, understand it's provision, and agree to abide by its terms during the course of my career as a school district employee.

24) Signature Signature

I understand that my typed signature is the legal equivalent of my handwritten signature on this document.

25) Date

Martin County Schools

Forms