1. EDUCATIONAL RECORD
    2. PROFESSIONAL MEMBERSHIPS/RECENT COMMUNITY ACTIVITIES
        1. REFERENCES



      APPLICATION FOR SUPERINTENDENT OF SCHOOLS

       
       
      Name:                                            Date:     


        Last      First      Middle
      Address:                                      E-mail:     


          Street    City    State  Zip
      Phone:                                                          Fax #:       


       Home      Business      Cell
      Present Position:        School District:
       
      Student Enrollment:        Number of Certified/Classified Staff:
       
      Annual Budget:        Present Salary:      
       





      EDUCATIONAL RECORD

       
      Name & Location of Institution Attended
      Year(s)
      Degree
      Major(s)
      Minor(s)
           
           
           
           
           
           


       
      Certifications/Licensure type
      Level
      Certification/Endorsement
      Issue Date
      Expiration Date
      State
            
            
            
            
            
            


       

       





      PROFESSIONAL MEMBERSHIPS/RECENT COMMUNITY ACTIVITIES

      (Indicate leadership responsibilities relevant to Superintendent position.)

            

       

            

       

            

       

            

       

      EXPERIENCE

      (List in chronological order beginning with the next most recent position following the position listed on page 1.)
      Dates
      Position/Institution/Location
      Supervisor’s Name & Title
      Supervisor’s Phone
      To:

       
           

         
            

         
      (Business)

             
      From:

       
                    

         
      (Home)

             
      Reason for leaving (please be specific): District Enrollment:

             
      To:     

         
        

         
        

         
      (Business)

             
      From:      

         
              

         
      (Home)

             
      Reason for leaving (please be specific):        District Enrollment:

              
      To:      

         
        

         
         

         
      (Business)

             
      From:     

         
               

         
      (Home)

             
      Reason for leaving (please be specific):       District Enrollment:

             
      To:    

         
         

         
         

         
      (Business)

              
      From:   

         
                

         
      (Home)

              
      Reason for leaving (please be specific):       District Enrollment:

              






      REFERENCES

      (Names of four persons who can discuss your experience and qualifications in detail.)
      Name
      Official Position
      Phone Number
       

            
       

             
      Business        
        Home
        Cell
                     Business         
        Home
        Cell
              Business
        Home
        Cell
              Business
        Home
        Cell
      AGREEMENT

      I authorize Everett Public Schools to make an investigation of my personal, educational, financial, vocational, or employment history. I authorize any former employer, firm, corporation, educational or vocational institution or government agency to provide the Everett Public Schools with any information they have regarding me. I hereby release and discharge Everett Public Schools and all of those who provide information from any and all liability as a result of furnishing and receiving this information.



      By my signature, I hereby affirm that, all answers to the questions in the application are true and complete. I agree that if I have provided false, misleading or incomplete information, Everett Public Schools may, at its sole discretion, terminate my employment. If such action is taken by the District, I agree that any employment contract or employment relationship deemed to exist shall be void from its inception.


      Federal and state criminal history background checks will be required of candidates. Any offer of employment is conditional and subject to the acceptable outcome of a criminal history and sexual misconduct background check

      Everett Public Schools complies with all state and federal rules and regulations and does not discriminate on the basis of race, religion, creed, color, national origin, sex, sexual orientation, marital status, age, veteran status, or disability. This holds true for all district employment and opportunities. Inquiries regarding compliance and/or grievance procedures may be directed to the school district's Affirmative Action Officer, Carol Stolz; Title IX Officer, Randi Seaberg; ADA District Coordinator, Kris McDowell or Section 504 Coordinator, Becky Ballbach, 3715 Oakes Avenue, Everett, WA 98201.  

       

       





      SIGNATURE                DATE

       

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      Revised: 12/08

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