SUBSTITUTE TEACHER APPLICATION

BON HOMME SCHOOL DISTRICT #04-2

District Office, PO Box 28, 1404 Fir Street, Tyndall, SD 57066

Name _______________________________ ____________________________ ___________

Last First M.I.

Address __________________________________ City___________________ State_____ ZIP________

Home Telephone (____) ____________________ Best time to call __________________________

Place of Employment ____________________________ May we contact you at work? ______Yes ______No

Work Telephone (___) _______________________ Best time to call __________________________

Social Security Number _________________________ Name as it is on Card ______________________

Which school(s) would you wish to be listed as a substitute? (Check any that apply)

_____ Bon Homme Hutterische Colony (K-12)

_____ Springfield Elementary (K-5)

_____ Tabor Elementary (K-5)

_____ Tyndall Elementary (PK-5)

_____ Bon Homme Middle School (6-8)

_____ Bon Homme High School (9-12)

High School subjects for which you do NOT wish to sub: ___________________________________

Education Level (Please check one)

_____ High School

_____ Bachelor’s Degree (not in education)

_____ Other ___________________________________

Please forward a copy of your diploma or transcript showing graduation from your highest level of education to the District Office.

_____ Bachelor’s Degree in Education

Do you have a valid teaching certificate? ____yes

Teaching Certificate: Number__________________ Expiration Date______________

Do you have an expired teaching certificate? ____ yes

Teaching Certificate: Number__________________ Expiration Date______________

Please forward a copy of your teaching certificate (expired or valid) to the District Office.

Have you been convicted of a CRIME in the last 7 years? _____Yes _____No (Conviction may be relevant if job related but does not necessarily bar you from employment). If yes, please explain: ________________________

________________________________________________________________________________________

Have you had a DCI/FBI background check with another school district? _______

If yes, which district(s)? _____________________________________________________________________

Do you have any past or current physical or mental health conditions which may affect the performance of your work? _____Yes _____No If yes, please explain:

Physical Health ______________________________________________________________________________

Mental Health _______________________________________________________________________________

Are you a US citizen? _____Yes _____No If no, do you have a Green Card? _____Yes _____No

List information regarding your interests, abilities, activities, and experience which you feel has a bearing on your qualifications for this position.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

EDUCATION

Name & Location From - To Degree(s) Date Received

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

EDUCATION REFERENCES

Full Name Title Complete Address Telephone

______________________________________________________________________________

______________________________________________________________________________

WORK EXPERIENCE

Begin with most recent job. Do not include part-time or summer work unless you consider it significant.

Name & Location From - To Nature of Work Supervisor

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

EMPLOYMENT REFERENCES

List information for those supervisors listed above in Work Experience.

Full Name Title Address, City, State, ZIP Telephone

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Bon Homme School District is an equal opportunity employer. The Bon Homme School District does not discriminate against any employee on the basis of sex, race, religion, national origin, age, height, weight, marital status, or handicap/disability unrelated to the employee's ability to perform his/her job.

I verify that the information given by me in this application is true, accurate, and complete. I understand that if I have given any false information on this application or if I have omitted any material fact, I may be disqualified from employment with Bon Homme School District, or if hired, I may be discharged upon discovery of such false statement(s) or omission(s). I understand that my employment with Bon Homme School District may be subject to a reference/background check. I hereby authorize Bon Homme School District to investigate the truthfulness of all statements made on this application and/or contact my former employer(s) and other listed reference(s) or any other person(s) who can verify any information submitted to Bon Homme School District in support of my application for employment. I hereby waive any right that I may have against any person contact by Bon Homme School District, including former employers who provide information concerning this application and I release each said person from liability for providing information.

________________________________________ ___________________________________

Signature Date