Sparta Community Unit School
District No. 140
Personnel Office
District Administrative Center
203B Dean Avenue
Sparta, IL 62286
(618) 443-5331
FAX: (618) 443-2023
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EMPLOYMENT APPLICATION – INSTRUCTIONAL STAFF
If you require any assistance or accommodation in the application or interview process, please contact the District ADA Coordinator at (618) 443-5331.
PERSONAL DATA
Last Name
First
Date:
Middle
Street address
City
State
Home Phone
Business Phone
Zip
Have you ever been interviewed for a position with us?
Yes
No
If yes; month & year: ____________________ Interviewed by: ___________________________
Position desired
Part-time
Full-time
Are you legally eligible for employment in the United States?
Yes
No
List any extra curricular activities you are qualified and willing to coach or direct.
Either
Other special training or skills (languages, machine operation, technology, etc.)
LICENSURE
Do you have a current Illinois license?
Yes
No
Type of license(s)
______________________
If so, list and include Illinois endorsements:
______________________
Grade Level(s)
_____________________ ____________________ ______________________
Subject(s) approved
_____________________ ____________________ ______________________
If you do not presently hold an Illinois license, are you licensable in IL?
______________________
For which teaching areas would you be licensed? _____________________________________________________________
All contracts require a valid Illinois teaching license for the grade level and subjects being taught to be filed in the Personnel Office within
ten days.
EDUCATION
School
College or university
College or university
College or university
High School
Other
Name and location of School
Major/
Minor
Total
GPA
Degrees/
Diplomas
EXPERIENCE
(Please list your present or most recent position first.)
TEACHING
1. Name and location of school
Telephone
Supervisor
Dates employed
Nature of work (Specify grades, subjects, extra curricular duties, etc.)
Reason for leaving
2. Name and location of school
Telephone
Supervisor
Dates employed
Nature of work (Specify grades, subjects, extra curricular duties, etc.)
Reason for leaving
3. Name and location of school
Telephone
Supervisor
Dates employed
Nature of work (specify grades, subjects, extra curricular duties, etc.)
Reason for leaving
4. Name and location of school
Telephone
Supervisor
Dates employed
Nature of work (specify grades, subjects, extra curricular duties, etc.)
Reason for leaving
STUDENT TEACHING
Name and location of school
Grade or subjects taught
Supervisor
Number of weeks
NON-TEACHING
Name and location
Date of Employment
Nature of Work
(Add more pages if necessary.)
Please indicate any job related activities, professional memberships, honors, offices held, or hobbies which you believe might help you to
perform the position(s) for which you have applied.
PROFESSIONAL DATA
Are you presently under contract?
Yes
No
When will you be available to begin work? ________________________________
Have you ever been dismissed, asked to resign, or non-renewed?
If yes, state where and state reasons:
Yes
No
Have you ever been convicted of a felony?
Yes
No
If yes, please describe below. Do not report any conditions for which the record had been expunged, sealed, or impounded.
REFERENCES (Include persons who have personal knowledge of your teaching ability.)
Name
Address
Vocation/Title
Telephone No.
WAIVERS AND NOTICES
I hereby authorize the District to conduct work history and reference checks to determine my acceptability for employment. Pursuant to the Illinois
Personnel Record Review Act, 820 ILCS 40/.01 et seq., I hereby waive written notice from my current employer and/or any previous employers and
authorize them to release information regarding any disciplinary actions taken against me within the past four years. Further, I hereby release the
officers, agents, employees and directors of each of my past employers and Sparta Community Unit School District No. 140, its officers, agents and
employees, from any and all liability arising from disclosure of personnel records and from verbal appraisals of my past performance. I understand and
agree that this waiver includes any and all manners of actions that I may not have or may have in the future concerning such disclosures, regardless of
their nature.
Signature __________________________________________________________ Date _______________________
I hereby authorize Sparta Community Unit School District No. 140 to forward my name to the Illinois Department of State Police for the purpose of
conducting a criminal background check as required by The Illinois School Code, Section 10-21.9, and agree to execute any forms required by said
department for such purpose. I understand that Sparta Community Unit School District No. 140 may further conduct a check for any indicated reports of
child abuse under the Abused and Neglected Child Reporting Act, 325 ILCS 5/1 et seq. Furthermore, I hereby indemnify, save and hold harmless
Sparta Community Unit School District No. 140, Randolph County, Illinois, and its officers, agents and employees from any claim of liability or damage
which may arise from the proceedings of the Illinois State Police or Department of Children and Family Services in conjunction with the above
background checks. I understand that an offer of employment, or continued employment if hired, is contingent upon my passing the Illinois State Police
and Child Abuse Registry background checks.
Signature ___________________________________________________________ Date ________________________
I understand that an offer of employment is contingent upon my submitting the required immigration (I-9) form and the health and medical examination
forms required by the District pursuant to The school Code, Section 24-5.
Signature ___________________________________________________________ Date ________________________
PERSONAL STATEMENT
Prepare a HAND WRITTEN STATEMENT to include any experience or talent which in your estimation will contribute to your success in the position for
which you are applying. Examples include scholastic distinctions, travel, community services or activities, foreign language skills, musical or artistic
talent, athletic achievement, coaching, journalism, dramatics, classroom projects/experiences, etc.
FILE COMPLETION
To be given consideration, it is the applicant’s responsibility to have the following information on file in the Sparta Community Unit District No. 140
District Office:
A. Letter of Application B. Completed Application Form C. Applicant’s Resume (optional) D. Criminal History Request
I hereby certify that the facts set forth in this application for employment are true, accurate and complete. I understand that any misrepresentations or
omissions of facts made by me on this application shall be sufficient cause for my disqualification for employment or termination of employment.
Further, I understand that, pursuant to 105 ILCS 5/22-6.5, my failure to provide requested employment or employer history which is material to my
qualifications for employment or the provision of statement which I do not believe to be true may be a Class A misdemeanor. I understand that this
application and records become the property of the District. I understand that an offer of employment is contingent upon my submitting the required
immigration (I-9) form and the health and medical examination forms required by the District pursuant to The School Code, Section 24-5.
Signature ____________________________________________________________ Date _______________________