Application for Employment: Licensed Staff - Mississippi Bend Area Education Agency

Application for Employment: Licensed Staff

The Mississippi Bend Area Education Agency does not discriminate on the basis of race, color, creed, gender identity, marital status, sex, sexual orientation, national origin, religion, age, socioeconomic status, or disability in its educational programs, services or employment practices. Inquiries concerning this statement should be addressed to Dr. Edward Gronlund, Equity Coordinator, at 563-344-6315.

* denotes required fields
GENERAL INFORMATION:
Position Desired: *
Date Available: * (mm/dd/yyyy)
First Name: *
Middle Name:  
Last Name: *
Address: *
City / State / Zip Code: *
Home Phone Number: *
Business Phone Number: *
Email Address: *
How did you learn of this opening? *
EDUCATION:
Please request that an up-to-date set of credentials such as those prepared by college placement office or employment agency be submitted for examination. Please provide a copy of your most recent degree and license or statement of professional recognition.
High School


Name:
City / State:
Major:
Minor:
College / University


Name:
City / State:
Major:
Minor:
Date of Graduation: (mm/dd/yyyy)
Highest Degree Achieved


Name:
City / State:
Major:
Minor:
Date of Graduation: (mm/dd/yyyy)
Total semester hours after highest degree conferred:  
WORK EXPERIENCE:
If presently employed, may we contact your employer for references? *
If no, why?
May we contact you at your place of employment? *
Job 1


Employer:
Address:
City / State / Zip:
Supervisor:
Phone Number:
Start Date: (mm/dd/yyyy)
End Date: (mm/dd/yyyy)
Position Held:
Salary:
Reason for Leaving:
Job 2


Employer:
Address:
City / State / Zip:
Supervisor:
Phone Number:
Start Date: (mm/dd/yyyy)
End Date: (mm/dd/yyyy)
Position Held:
Salary:
Reason for Leaving:
Job 3


Employer:
Address:
City / State / Zip:
Supervisor:
Phone Number:
Start Date: (mm/dd/yyyy)
End Date: (mm/dd/yyyy)
Position Held:
Salary:
Reason for Leaving:
Job 4


Employer:
Address:
City / State / Zip:
Supervisor:
Phone Number:
Start Date: (mm/dd/yyyy)
End Date: (mm/dd/yyyy)
Position Held:
Salary:
Reason for Leaving:
EMPLOYMENT REFERENCES:
List below three references, including particularly persons under whom you have worked. Please provide letters of reference from those persons with your application if you do not have letters in your credentials.
Reference 1


Name: *
Position: *
Address: *
City / State / Zip: *
Day Phone Number: *
Reference 2


Name: *
Position: *
Address: *
City / State / Zip: *
Day Phone Number: *
Reference 3


Name: *
Position: *
Address: *
City / State / Zip: *
Day Phone Number: *
PROFESSIONAL STANDARDS:
Notice: Candidates must be able to meet the requirements for Iowa Certification. Eligible candidates will be interviewed following a screening of their written applications. For information regarding Iowa Certification, contact the Board of Education Examiners, Grimes State Office Building, Des Moines, Iowa 50309. (515-281-3483)
Do you currently hold an Iowa Teacher License? *
If so, Iowa Certification Number
What Iowa certifications, endorsements or approval do you have? *
If applicable, do you have a Statement of Professional Recognition?
Have you successfully completed a probationary period in an Iowa School District or Area Education Agency? *
Where?
Are you currently collecting IPERS benefits? *
HEALTH:
Do you any physical limitations which would prevent you from performing the work you are seeking? *
I have reviewed the description(s) for the position(s) for which I have applied and I am able with or without reasonable accommodations, to fulfill the essential functions of the position(s). *
If there are reasonable accommodations needed, please list the accommodation(s) needed and the function(s) needing accommodation:
BACKGROUND:
Are you a U.S. Veteran? *
If yes, please provide dates of active service:  
Also, submit proof of honorable service (DD214):  
(doc,docx,pdf,txt)
Have you ever been convicted of, or entered a plea of guilty to any offense other than a minor traffic violation? *
Are you on a sex offender registry? *
Are you on the Department of Human Services’ child registry? *
A "yes" answer does not automatically eliminate applicant from further evaluation.
UPLOAD DOCUMENTS:
#1:  
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#2:  
(doc,docx,pdf,txt)
#3:  
(doc,docx,pdf,txt)
#4:  
(doc,docx,pdf,txt)
#5:  
(doc,docx,pdf,txt)
#6:  
(doc,docx,pdf,txt)
#7:  
(doc,docx,pdf,txt)
AGREEMENTS:

I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts called for on this application is cause for dismissal. I also understand I may be assigned to positions other than that for which I initially made application and that my location of work and/or work hours may be changed. I agree that if employed by the Agency, in consideration for such employment, I shall become familiar with and comply with policies, procedures, and safety practices of the Agency as they exist. I authorize persons, schools, current employer (if applicable) and previous employers and organizations named in this application (accompanying resume, if any) to provide this Agency with any relevant information which may be required to arrive at any employment decision. I understand that a criminal records background check will be completed.

I understand that this application is not a contract of employment and that no hiring is legal until approved by the Mississippi Bend AEA Board of Directors.

Applicant's Signature: *

The Iowa Legislature passed a law effective July 1, 2008 that prohibits smoking in the Mississippi Bend Area Education Agency (Agency) facilities and its grounds; including parking lot, and vehicles.

Beginning July 1, 2008 customers and employees of the Mississippi Bend Area Education Agency are prohibited from smoking on any Agency owned, leased or rented property. This includes all offices.


Inquires should be addressed to:
Dawn Meier, Human Resources Specialist
729 21st Street
Bettendorf, IA 52722
(563) 344-6411
 
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