39LQH6WUHHW0RXQWDLQ%ook, AL 35213
Voice: 205- 414-3833
FAX: 205-877-8303
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www.mtnbrook.k12.al.us/
Please complete the form, then print for your records. Press SUBMIT to email; then RESET to clear.
Application for Certified Positions
PERSONAL DATA:
NAME:
DATE:
SOC. SEC. #:
PHONE #:
CELL #:
ADDRESS:
CITY/STATE/ZIP:
EMAIL ADDRESS:
EDUCATION DATA:
HIGH SCHOOL:
YEAR GRADUATED:
COLLEGE/UNIVERSITY:
MAJOR:
DEGREE:
DATE:
GPA:
MAJOR:
DEGREE:
DATE:
GPA:
HOURS ABOVE BS/BA DEGREE:
GRADUATE SCHOOL:
HOURS ABOVE MS/MA DEGREE:
ALABAMA TEACHING CERTIFICATE #:
TYPE/RANK
DATE ISSUED
EXPIRATION DATE
AREA OF ENDORSEMENT
PREFERRED TEACHING OR SPECIALITY AREA:
TEACHING AND ADMINISTRATIVE EXPERIENCE:
School Name/Address
Subject/Grade
TOTAL YEARS EXPERIENCE:
NCLB Highly Qualified:
PRESENT SALARY:
Yes
NATIONAL BOARD CERTIFICATION
ALABAMA FINGERPRINT CLEARANCE DATE:
Certified Position
Dates
No
YES
No
January 25, 2013
1
REFERENCES: (College Instructors/Former Employees/Supervisors)
Name/Position
Address
Phone
PROFESSIONAL INFORMATION:
Are you interested in a teacher’s assistant position if other positions are not open?
No
Yes
Are you interested in athletic coaching or in sponsoring other student activities?
Yes
No
If yes, indicate area(s):
Has your teaching contract ever been non-renewed or terminated?
No
Yes
Have you ever been convicted of or entered a plea of no contest to a felony or misdemeanor other than a minor
traffic violation?
Yes
No
If you answered “Yes”, please provide details of conviction including date and place of conviction, and submit
court certified copies of the judgment, conviction, and sentencing.
I hereby certify that all the information I have provided in this application is true and correct. I give my
permission for the Mountain Brook Schools to contact any references or prior employers given in conjunction
with this application. I agree that falsification of any part of this application may be sufficient cause for
dismissal. References and personal information that become a part of this application will be regarded as
confidential and shall not be revealed to me.
Signature of Applicant:
Date:
ALL INFORMATION MUST BE COMPLETED!
It is the policy of the Mountain Brook Board of Education, including any schools, and programs under its
control, that no person shall, on the grounds or race, color, disability, sex, religion, national origin, or age, be
excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program,
activity, or employment.
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Certified Position
January 25, 2013
2