APPLICATION FOR TEACHING POSITION                                                         Madison Local School District 1379 Grace Street
Mansfield, Ohio 44905-2742 Date __________________________	419-589-2600
419-589-3653 fax Name:
Last ___________________________first__________________________ middle ________________

Address: _____________________________________________________

_____________________________________________________ Phone: ___________________________

Current Position: ____________________________________	Are you under contract for next year? _____________

POSITION(s) DESIRED (check all that apply)

____ PS – 3 Early Childhood	_____ 4-9 Middle Childhood	____ 9-12
____ Special Education: Area(s) ________________________________________________________________________________ ____ High School: Area(s) ____________________________________________________________________________________ ____ Vocational School: Area(s) _______________________________________________________________________________ ____ Other area(s) Subject: Area(s) _________________________________________________________________________ ____ Extracurricular Areas Able/Willing to Direct/Coach: ___________________________________________________________

CERT./LICENSURE(s) ___ please indicate if State is Other Than Ohio: STATE: _______________________________________

Number	Title	Issue Date	Expiration Date

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Please include any copies of your certificate(s) with this application.

EDUCATION

Under-Graduate

Graduate Degree

Other(s)

Dates of Year of	Attendance
School/Institution	Major	Graduation	From-To

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Please include any copies of your transcript(s) with this application.

MILITARY EXPERIENCE	Number of years/months

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TEACHING EXPERIENCE

School District Address/Location

Position	 Dates From-To

Number of Years

Grade/Subject(s) Taught

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WORK EXPERIENCE (non-teaching)	Position	Dates From-To

Contact Address/Phone

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REFERENCES
Name	Address	Position	Phone #

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OTHER INFORMATION

The applicant, having applied for employment with the Madison Local Board of Education hereby agrees to be fingerprinted and understands that his/her fingerprints, name, address, date of birth and social security number will be submitted to the State of Ohio, Bureau of Criminal Identification and Investigation (B.C.I.).

Due to the length of time required for completion of the records check, it may occasionally be necessary to employ a person prior to the Board of Education’s receipt of the results of the criminal records investigation. In these cases, the Board of Education shall rely on the information provided in the employment application. However, by signing this document the applicant specifically agrees that if employed by the Madison Board of Education prior to the receipt of a response from the BCI and if the subsequent report of the BCI is received which is not consistent with the answer to the above question(s), the action of the Board of Education of employment shall be void without any further action by either party, and that the employment will cease immediately without the necessity of proceedings to formally terminate the contract of employment.

The Madison Local Schools are committed to a policy of nondiscrimination in relation to race, color, sex, religion, age, handicap, or national origin.