APPLICATION FOR CONSIDERATION OF PROFESSIONAL POSITION

Information submitted by the applicant through this form will be used by ANW Special Education Cooperative to screen your qualifications for employment. If a suitable match is determined by ANW, you will be contacted to proceed with the application process.
 

PERSONAL INFORMATION

Title: (Mr., Mrs., Miss, Doctor, etc.)

First Name: 

Middle Initial: 

Last Name:

Social Security Number: 

Address: 

City:

State: 

Zip Code: 

Home Phone: 

Work Phone: 

AREAS OF INTEREST

Please list the position(s) or area(s) for which you are applying for:

Please specify exceptionalities and certification(s):

ESL Endorsement:YES NO 
Bilingual Endorsement:YESNO 

Sport or Student Activity you would feel qualified to coach or sponsor:

List special strengths, talents and/or unique qualities you possess which you believe might be useful in your employment, including any sign language skills or training:

PROFESSIONAL EDUCATION/QUALIFICATIONS

Major

Minor

University

Date Completed

BA/BS

MA/MS/MEd

Ed.S./Ph.D

FULL TIME TEACHING/CLINICAL/INTERNSHIPS (Contract and Credentialed)

ENDORSEMENTS/CLINICAL/LICENSES

Type(s):   State:   Expires:

STUDENT TEACHING/CLINICAL/INTERN EXPERIENCE

OTHER EXPERIENCE(S)

Have you met Kansas Pre-certification testing requirements?YES NO 

PERSONAL DATA

Have you previously held a teaching position with us? YES NO

If yes, give dates and names under which employed, if different from this application: 

Have you ever been denied a teaching certificate/license or had your teaching certificate/license 
suspended or revoked?YES NO

If yes, Check the action taken: 
DENIEDSUSPENDED REVOKED

Have you ever been convicted of, or are your currently charged with, a crime for other than a 
minor traffic violation? YES NO

If yes, please give details below: 

Special Skills/Interests/Other subjects you are credentialed to teach, activities qualified to 
direct, sports qualified to coach or positions qualified to fill: 

Please specify any language (other than English) that you are proficient in: 

PROFESSIONAL REFERENCES

 Include a minimum of three who have knowledge of your professional/teaching experiences:
Make sure to include the Name, Position, and Address/Telephone Number of each reference.

Are you legally authorized to work in the United States of America? YES NO

AUTHORIZATION AND RELEASE

I HEREBY CERTIFY THAT THE STATEMENTS MADE BY ME IN THIS APPLICATION ALL RELATED INFORMATION WHICH I HAVE PROVIDED ARE TRUE, ACCURATE, AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
YESNO 

I EXPRESSLY AUTHORIZE THE RELEASE TO THE EDUCATIONAL AGENCY RECEIVING THIS APPLICATION ANY RECORDS OR INFORMATION WHICH MAY REFER OR RELATE TO THIS APPLICATION FOR EMPLOYMENT, INCLUDING, BUT NOT LIMITED TO, RECORDS OF EDUCATIONAL INSTITUTIONS, LAW ENFORCEMENT OR CRIMINAL JUSTICE AGENCIES, AGENCIES MAINTAINING CHILD ABUSE RECORDS, AND PREVIOUS EMPLOYERS. I HEREBY RELEASE AND DISCHARGE THE EDUCATIONAL AGENCY RECEIVING THIS APPLICATION AND ANY RESPONSIBLE PERSON(S) EMPLOYED BY THE AGENCY FROM ANY AND ALL CLAIMS AND LIABILITY WHICH I MAY HAVE OR EVER CLAIM TO HAVE RELATING TO INFORMATION PROVIDED TO THE EDUCATIONAL AGENCY AS PART OF THIS APPLICATION FOR EMPLOYMENT.
YES NO 

E-Mail Address: (required)

    
PLEASE ONLY CLICK THE SUBMIT BUTTON ONCE AND ALLOW TIME FOR THE APPLICATION
TO PROCESS. THIS MAY TAKE A FEW MINUTES TO COMPLETE. THANK YOU.