“An Equal Opportunity Employer”
A E Phillips Laboratory School
APPLICATION FOR EMPLOYMENT
P O Box 10168 Telephone: (318) 257-3469
Ruston, LA 71272 FAX: (318) 257-3676
Dr. Jenny Blalock Lori Kelly / Stephanie Whitten
Director Assistant Directors
Name _________________________________________________________________________________________________________________
Last First Middle Maiden
Address ______________________________________________________________________________________________________________
Street or Box Number City State ZIP
Primary
Phone #:
-
-
Alt. Contact #:
-
-
Social
Security
Number:
-
-
Race
Date of
Birth:
-
-
Degree
BA /
BS
MA /
MS
M+30
Ed. Spec.
Ed.D /
Ph.D.
(Circle One)
Today’s Date_____________________________________________ Email:____________________________________________________
EDUCATION
Dates Attended
School
Location
From
Until
Major
Minor
Degree
Earned
High School
College or University
STUDENT TEACHING INFORMATION
Grade or Subject
Taught
School
Address
Supervising
Teacher
Final Grade
TEACHING CERTIFICATE INFORMATION
Are you currently certified? If yes, please complete the following:
State
Type
Number
Date
Issued
Period
Valid
Areas of Certification
If you are not certified, please explain:
Teaching Preference: ___________________________________________________________________________________________________
“An Equal Opportunity Employer”
TEACHING EXPERIENCE (Beginning with most current)
Name of School and Address
Parish or
County
Telephone
Grade or
Subject
# of
Years
Dates
NON-TEACHING EXPERIENCE
Position
Name of Organization
Telephone
Supervisor
# of Years
Dates
PROFESSIONAL REFERENCES
Name
Address
Telephone
Relationship
GENERAL INFORMATION
Are you presently under contract with any other school system? ___________________ If Yes, expiration date:
Have you ever been discharged, requested to resign, or refused tenure?
If yes, please explain:
Have you ever taught in Lincoln Parish Schools? _________________ Dates:
Are you retired from a Louisiana retirement system? _____________ If yes, which system?
Have you ever been convicted of, plead nolo contendere (no contest) to, or had a criminal offense expunged?
DO NOT INCLUDE MINOR TRAFFIC VIOLATIONS. If YES, give the date, nature, and disposition of the offense.
Are there any current charges pending against you? _______________
Do you have military service that needs to be considered?
“An Equal Opportunity Employer”
Before you return this application, please attach the following items:
1. A copy of your most current teaching certificate or a letter from the University
proving graduation or that certificate has been applied for.
3. A copy of your NTE/Praxis Scores (If less than 3 years
experience)
2. An official copy of your most recent final evaluation report/results (COMPASS in
LA) from previous employer
4. A transcript of all college work (if less than 3 years
experience).
Louisiana Tech University and A E Phillips Laboratory School are an Equal Opportunity Employer. Applicants are considered for employment on the
basis of qualifications without regard to age, race/color, religion, national origin, sex, or disability.
.
AUTHORIZATION AND RELEASE
IMPORTANT: READ CAREFULLY
Louisiana Revised Statutes 17:3884 provides that a school board considering the employment application of a person who has been
evaluated in another school system shall request such person’s evaluation results as part of the application process and that the
board to which the application is being made must inform the applicant of this requirement. Accordingly, A E Phillips Laboratory
School will request evaluation results from the school districts which you have listed on your application. You will be given an
opportunity to review the evaluation results received and to provide a response or information as you deem appropriate. Written
responses will be retained with your application.
Louisiana Revised Statutes 17:15 requires all applicants for employment to be fingerprinted in order to assist in a background check
of the employee. Should any applicant (or employee) have been convicted of or plead guilty to one of the criminal offenses set forth
in Louisiana Revised Statutes 17:587.1(C), that person is generally precluded from further employment with the school system.
Louisiana Revised Statutes 17:81.9 requires a school board/school receiving an application to request that all current and prior
school board employers of the applicant to provide it with all information relative to instances of sexual misconduct with students
committed by the applicant, if any. This law further provides that the applicant must release all such employers from liability as may
result from the release of such information.
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AUTHORIZATION AND RELEASE
I certify that the information which I have provided in my application is true and complete. I understand that furnishing false
information or omitting information could disqualify me from consideration for employment or could lead to my discharge from
employment. You are hereby authorized to request documentation and information relative to my prior teaching experience,
evaluations, and sexual misconduct with students from all current or prior school system employers. In consideration of your
accepting and considering my job application, I hereby release Louisiana Tech University/A E Phillips Laboratory School and all
current and former employers, their agents and employees from any liability connected with such disclosures and do hereby
authorize my current and prior employers to release such information and documentation as may be requested in connection with
the application process to A E Phillip Laboratory School.
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____________________________________________
Print Full Name
____________________________________________
Applicant's Signature
______________________
Date
