Faculty Application Faculty application APPLICATION FOR FACULTY EMPLOYMENT Name First Middle Last Social Security Number* Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Phone Position Applying for* Resume and Cover Letter Drop files here or Please upload Resume and Cover Letter here or mail to: Administrator 452 Ebenezer Road Lebanon, PA 17046 Church you attend Regular attendee? Yes No Pastor/Minister’s Name Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Years attending this church May we contact your church leadership for a reference? Yes No What are your career goals? Why are you applying for a position with this school? EDUCATIONAL AND EMPLOYMENT BACKGROUND High School School Location School Location Colleges and Universities Name of Institution Location Degree Name of Institution Location Degree Major Number of Semester Hours Minor Number of Semester Hours Teaching certification(s) and effective date: Active or inactive? Active Inactive If inactive, number of hours required to bring to active status: List any other professional certifications: Employment Experience List chronologically all work experience. Inclusive Dates (Mo/Yr to Mo/Yr) Position Employer and Address Inclusive Dates (Mo/Yr to Mo/Yr) Employer and Address Position REFERENCES List the names of three (3) persons who know directly of your work professionally or of your qualifications for teaching. Reference #1* First Last Relationship Phone Number Reference #2* First Last Relationship Phone Number Reference #3* First Last Relationship Phone Number When did you leave your last position? Why did you leave your last position? Have you ever been convicted of, currently charged with, or been under investigation for any criminal offense? Yes No If “yes”, please give details. If offered a position, how soon could you begin work? May your present employer be contacted? Yes No If “no”, please explain. Minimum Acceptable Salary CERTIFICATION* I give the school and its designated representatives permission to contact the schools, employers, and references named in this application and to investigate the information I have provided and to seek and obtain any other information the school considers relevant. I release the school and its representatives and the persons and organizations who provide this information from any liability for doing so. I further waive the right ever to personally view any references given to the school. In addition, I declare all my statements and answers which are part of this application to be complete and correct to the best of my knowledge. STATEMENT OF CHRISTIAN FAITH AND COM MITMENT 1. Write a brief statement including your personal relationship to Christ, your present relationship to the church and how these relationships influence your everyday life and commitment. 2. Are you willing to be guided by the administration of the school? Are you open to consider changes in life and conduct that may be requested? 3. Comments or questions. ACT 151 (PA Child Abuse History Clearance) Each candidate must submit a copy of an official clearance statement obtained from the Pennsylvania Department of Public Welfare or a statement from the Department of Public Welfare that no record exists. This clearance must be current within one year. The applicant MUST submit the ORIGINAL report prior to employment. ACT 34 – PA State Police Criminal Record Check * This report must be current within one year. PDE-6004 ACT 114 of 2006, Section III of the Public School Code * – Federal Fingerprinting This clearance must be current within one year. ACT 168 – Commonwealth of PA Sexual Misconduct/Abuse Disclosure Release * Employment history review submitted by hiring school. ACT 24 – Arrest/Conviction Report and Certification Form * Required for employment decisions in a school entity. * These forms are available on the PA Department of Education website.