Revised: 12/08
Page 1 of 3
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
Revised: 12/08
Page 2 of 3
PROFESSIONAL MEMBERSHIPS/RECENT COMMUNITY ACTIVITIES
(Indicate leadership responsibilities relevant to Superintendent position.)
E
XPERIENCE
(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:
Revised: 12/08
Page 3 of 3
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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