Application

REGIONAL SCHOOL DISTRICT #10

24 Lyon Road

Burlington, CT 06013

(860) 673-2538

Fax: (860) 675-4976

Online Employment Application

All fields labeled with an (*) are required fields.

Teaching Area: *

First Name: *

Middle Name:

Last Name: *

Date of Application: *

E-Mail Address: *

Type of Position Applying for:

Regular Position

Substitute Position

Other - Please specify:

Present Address:

Street: *

City: *

State: *

Postal Code: *

Telephone Number: *

Social Security Number: (optional)

Permanent Address:

Street: *

City: *

State: *

Postal Code: *

Telephone Number: *

Designate the type of position for which you are applying. List grade, subject, specialty area, or specific position. (i.e. social worker, librarian, primary grade teacher, etc.) based upon qualifications, certification, and preference.

What type of position are you applying for?

1. *

2.

3.

4.

Connecticut Teacher Certification Requirements:

Date Passed PRAXIS I:    *

Date Passed PRAXIS II:   *

Connecticut Certification

Type of Certification:    *

Endorsement Area (s) *

Date of Certificate:       *

Educational Preparation:

Undergraduate School:

School Name: *

Location: *

Major: *

Degree Diploma: *

Date Graduated: *

Cumulative Grade Point Average: *

Second Undergraduate School:

School Name:

Location:

Major:

Degree Diploma:

Date Graduated:

Cumulative Grade Point Average:

Graduate School:

School Name:

Location:

Major:

Degree Diploma:

Date Graduated:

Cumulative Grade Point Average:

Second Graduate School:

School Name:

Location:

Major:

Degree Diploma:

Date Graduated:

Cumulative Grade Point Average:

Student Teaching or Internship Experiences:

First Teaching or Internship Experiences:

Time Frame (MM/YY-MM/YY):

School:

Location (City/State):

Grade/Subject:

Supervising Teacher:

Phone Number:

Second Teaching or Internship Experiences:

Time Frame (MM/YY-MM/YY):

School:

Location (City/State):

Grade/Subject:

Supervising Teacher:

Phone Number:

Third Teaching or Internship Experiences:

Time Frame (MM/YY-MM/YY):

School:

Location (City/State):

Grade/Subject:

Supervising Teacher:

Phone Number:

Contracted Employment Experiences In Education

Most recent contracted employment experience in education:

Time Frame (MM/YY-MM/YY):

School:

Location (City/State):

Nature of Position, Grade/Subject:

Full Time?:

Number of Years:

Reason for Leaving:

Other contracted employment experience in education:

Time Frame (MM/YY-MM/YY):

School:

Location (City/State):

Nature of Position, Grade/Subject:

Full Time?:

Number of Years:

Reason for Leaving:

Other contracted employment experience in education:

Time Frame (MM/YY-MM/YY):

School:

Location (City/State):

Nature of Position, Grade/Subject:

Full Time?:

Number of Years:

Reason for Leaving:

Other contracted employment experience in education:

Time Frame (MM/YY-MM/YY):

School:

Location (City/State):

Nature of Position, Grade/Subject:

Full Time?:

Number of Years:

Reason for Leaving:

Other Employment Experience:

(Business, Trade, Volunteer, Military, etc.)

First Other Employment Experience:

Time Frame (MM/YY-MM/YY):

Firm/Institution:

Location (City/State):

Experience:

Number of Months:

Second Other Employment Experience:

Time Frame (MM/YY-MM/YY):

Firm/Institution:

Location (City/State):

Experience:

Number of Months:

Third Other Employment Experience:

Time Frame (MM/YY-MM/YY):

Firm/Institution:

Location (City/State):

Experience:

Number of Months:

Professional References

List at least four individuals who are sending letters of reference on your behalf and who have first-hand knowledge of your professional competence. You may include non-confidential letters of reference with this application.

First Professional Reference:

Name: *

Street: *

City: *

State:    *

Postal Code: *

Position: *

Telephone Number: *

Second Professional Reference:

Name: *

Street: *

City: *

State:    *

Postal Code: *

Position: *

Telephone Number: *

Third Professional Reference:

Name: *

Street: *

City: *

State:    *

Postal Code: *

Position: *

Telephone Number: *

Fourth Professional Reference:

Name: *

Street: *

City: *

State:    *

Postal Code: *

Position: *

Telephone Number: *

Activities and Interests

1. Please list any college activities in the space below: (clubs, publications, athletics, etc.)

2. Please list any other skills and talents in the space below: (art, music, foreign language, athletic coaching)

3. Please list and hobbies, leisure time interest and travel in the space below:

4. Please list and volunteer services (civic welfare, organization membership)

5. Please list any honors or recognition in the space below:

Verification Of Records

In answering the following questions concerning criminal history, please disregard criminal charges or convictions that have been erased pursuant to Connecticut General Statutes §146b-146, 54-76o, or 54-142a. Criminal records pertaining to the following are subject to such erasure: (a) a finding of delinquency or that a child was a member of a family with services needs, (b) an adjudication as a youthful defender, (c) a criminal charge that has been dismissed or nolled, (d) a criminal charge for which you have been found not guilty, and (e) a conviction for which you received an absolute pardon. You are not required to disclose such records if they have been erased. Any person whose criminal records are erased as described above shall be considered to have never been arrested and may so swear under oath.

1. Have you ever been convicted of a felony or any other criminal offense, either within or outside the State of Connecticut, other than a conviction of which the records have been erased?

No

Yes If yes, identify the approximate date, location and nature of each such conviction in the space provided below. For purposes of this application a plea of “no contest” or “nolo contendere” is a conviction.

2. Has there ever been a disposition of criminal charges against you other than a dismissal or acquittal, or an arrest, criminal charge or conviction for which the records have been erased?

No

Yes If so, identify the approximate date, location and nature of each such disposition and the nature of the charges against you in the space provided below:

3. Are any criminal charges currently pending against you either within or outside the State of Connecticut?

No

Yes If so, identify the jurisdiction in which such charges are pending, the nature of the charges against you and provide an explanation in the space provided below:

4. Are you currently enrolled in a program of deferred adjudication (e.g. accelerated rehabilitation, pre-trial drug or alcohol education pursuant to Connecticut General Statutes §54-56g)?

No

Yes If so, identify the jurisdiction in which such program is pending and provide an explanation of the nature of such program and the criminal charges against you in the space below:

5. Has your teaching certificate ever been suspended or revoked?

No

Yes If yes, please explain, in writing in the space below:

6. Has your contract every failed to be renewed?

No

Yes If yes, please explain, in writing, in the space below:

     I understand that if I am employed by the Region 10 Board of Education, I will be required to submit to a state and national criminal history records check within a period of 30 days from my date of employment and I will be required to submit to fingerprinting, at my expense, for purposes of submitting my fingerprints to the Federal Bureau of Investigation for a national criminal history records check. I further understand and agree that if I have been convicted of a crime that has not been disclosed as part of my application for employment, my employment will be subject to termination.

     I hereby authorize any and all law enforcement agencies, current and former employers, credit agencies, academic institutions and any other persons or entities to supply any information regarding my background to the Region 10 Board of Education and its agents and employees, and I hereby release all such former employers, law enforcement agencies, credit agencies, academic institutions, or other persons or entities, and their agents and employees from any liability arising from the supplying and use of such information.

     I declare under the penalties of false statement that I have read and understand the terms of this employment application and attest to the truth and accuracy of the information I have provided herein. I understand that false or misleading statements on this application shall be a basis for disqualification from further consideration for employment and, if I am employed, for dismissal from employment.

Notice of Non-Discrimination

Regional School District #10 does not discriminate on the basis of race, color, national origin, handicap, sexual orientation, sex or age, in admission to, access to, treatment in, or employment in its programs and activities. The Coordinator of the District's efforts to comply with section 504 of the Rehabilitation Act of 1973 and the American with Disabilities Act is the Director of Special Services (860-673-6195). The Coordinator of the District's efforts to comply with the Title IX of the Education Amendments of 1972 and issues regarding sexual harassment is the Director of Curriculum and Instruction (860-673-2538). Any inquires regarding the application of the District's non-discriminatory policy (Title VI) may be referred to the Superintendent of Schools at (860-673-2538).

I hereby acknowledge that I have read the above statements and understand them.

No, I do not agree with the above statements the I have read

Yes, I do agree with the above statements that I have read

Online Application Information

If you wish to send us your resume please do so by attaching it to a separate e-mail, and send it to application@region10ct.org. Please be sure to put in the subject your name and date of application. We can only read the following formats:

Microsoft Word

HTML

TXT files

Once you click Submit your application will be placed in our database. We suggest that you print your application before pressing the submit button.

If there is anything that you wish to add you may do so in the space below. This information will appear on your application. (do not place your resume in this space):

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