ApplicationQuestionnaire
CURRENT STATUS
Please answer the following questions by circling the appropriate response:
A. Do you currently hold a valid Iowa Superintendent’s Endorsement #61 or #171?
B. If you do not hold the Iowa Superintendent's Endorsement, are you eligible for
such endorsement?
C. Are you currently under contract with any school district for next year?
Yes
No
Yes
Yes
No
No
Yes
No
Yes
Yes
Yes
Yes
No
No
No
No
ADDITIONAL INFORMATION
If your answer is “yes” to any of the following, please attach an explanation:
A. Have you ever been convicted of a violation of law other than a minor traffic violation?
The term “convicted” includes any conviction, a guilty plea, a plea of nolo contendere or
no contest, a suspended sentence, and a deferred judgment.
B. In connection with your professional responsibilities, have you ever been the subject of a
complaint or been disciplined by a court or licensing Board of any state?
C. Has there been any incident that could affect your ability to lead our school district?
D. Are you listed on a sex offender registry?
E. Are you listed on the Department of Human Services Child Abuse Registry?
I hereby certify that the statements made by me in this application and all related information which I have provided are true, accurate,
and complete to the best of my knowledge. I understand that if I provide any false, inaccurate, or incomplete information, I will not be
eligible for employment, or, if I am hired, I will be subject to disciplinary action or dismissal regardless of the date on which the District
discovers the violation of its policy regarding application form dishonesty.
I acknowledge that the position of superintendent is a position of public trust and I specifically authorize the Board, or its agents, to
contact references, to investigate my background, and to make such other inquiries as the Board in its discretion deems relevant to
assess my qualifications for the position of superintendent. I authorize former employees, my references, or any other person
contacted by the Board or its agents in investigating the merits of my application to disclose personnel records and appraisals of my
performance or information about my qualifications for the position of superintendent, and release them from any liability for such
disclosure.
I understand that if I apply for employment with the School District, the District may conduct a check of my criminal history. I agree to
sign a Waiver authorizing the District to obtain a check of my criminal history, and I further agree to provide all information necessary to
obtain this criminal history check.
Signature
Date
Equal Opportunity Employer/Affirmative Action Employer
2
REQUEST FOR CLOSED SESSION
As an applicant for the position of superintendent, I have submitted to the Board an employment application
form and related materials. It is my understanding that my employment application form and related materials
are protected from public disclosure by virtue of Iowa Code Section 22.7(18) and the ruling to the Iowa
Supreme Court in the case of City of Sioux City v. Greater Sioux City Press Club, 421 N.W. 2d 895 (Iowa
1988), and that it may be reviewed by the Board in closed session as provided by Iowa Code Section
21.5(1)(a).
As an applicant for the position of superintendent, I also understand that the Board will hold a full and frank
discussion of my candidacy including, but not limited to, a discussion of:
1. Any negative performance evaluations, which I may have received.
2. Any employment relationships to which I may have been a party which were terminated by
the employer.
3. Any employment relationships to which I may have been a party which were terminated by
me but at the request or suggestion of the employer.
4. Any disciplinary action (including warnings, reprimands, suspensions, demotions, or letters
of corrective action), which may have been taken against me by an employer.
5. Any negative, adverse, or unfavorable report or reference, which the Board has received
regarding me from any and all sources.
I believe that the discussion of the categories of information set forth above may cause needless and
irreparable injury to my reputation and that the Board may hold its discussion or conduct its evaluation of my
professional competence for hiring as superintendent in closed session as provided by Iowa Code Section
21.5(1)(i).
Signature ______________________________________ Date _________________
3
OPEN MEETINGS LAW WAIVER AND CONSENT
As an applicant for the position of superintendent, I have submitted to the Board an employment application
form and related materials. It is my understanding that my employment application form and related materials
are protected from public disclosure by virtue of Iowa Code Section 22.7(18) and the ruling to the Iowa
Supreme Court in the case of City of Sioux City v. Greater Sioux City Press Club, 421 N.W. 2d 895 (Iowa
1988), and that it may be reviewed by the Board in closed session as provided by Iowa Code Section
21.5(1)(a).
As an applicant for the position of superintendent, I also understand that the Board will hold a full and frank
discussion of my candidacy including, but not limited to, a discussion of:
1. Any negative performance evaluations, which I may have received.
2. Any employment relationships to which I may have been a party which were terminated by
the employer.
3. Any employment relationships to which I may have been a party which were terminated by
me but at the request or suggestion of the employer.
4. Any disciplinary action (including warnings, reprimands, suspensions, demotions, or letters
of corrective action), which may have been taken against me by an employer.
5. Any negative, adverse, or unfavorable report or reference, which the Board has received
regarding me from any and all sources.
I understand the public discussion of the categories of information set forth above may cause needless and
irreparable injury to my reputation and that the Board may hold its discussion or conduct its evaluation of my
professional competence for hiring as superintendent in closed session as provided by Iowa Code Section
21.5(1)(i).
I hereby waive my right to request that the Board discuss my application form and related materials and my
candidacy for the position of superintendent in a closed session, and I consent to a discussion of my
application form and related materials and my candidacy for the position of superintendent in an open session.
I hereby release and discharge the Board and all participants in the meeting from any and all claims and
liability which I may have or ever claim to have as a result of any statements made in the discussion of my
application form and related materials and my candidacy for the position of superintendent in an open session.
Signature
Date ________________
*NOTE: This waiver does not apply to the candidate’s closed file credentials.