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HCS-I

Revised 5/86

HOLMES COUNTY SCHOOL DISTRICT
P. O. Box 630
Lexington, MS 39095
662-834-2175 (Fax # 662-834-9060)

______________________
Date
POSITION(S) APPLYING FOR (CIRCLE ONE):

Teacher

Coach

Counselor

Supervisor

Administrator

NAME____________________________________________________________ Social Security No. ____________________
Last

First

Middle

CURRENT ADDRESS___________________________________________________________________________________
Street/PO Box
City
State
Zip
Phone_________________________________
Area Code

Telephone

PERMANENT ADDRESS________________________________________________________________________________
Street/PO Box

City

State

Zip

Phone_________________________________
Area Code

Telephone

DEGREE(S) EARNED (CIRCLE ALL THAT APPLY)
BS

BA

MASTER’S

VOCATIONAL

SPECIALIST

DOCTORATE

MISSISSIPPI TEACHING CERTIFICATE ENDORSEMENT(S):
Class (AAAA, AAA, AA, A)
Type
Subject Area
_______________
Administrator
_________________________
_______________
Supervisor
_________________________
_______________
Secondary Teacher
_________________________
_______________
Elementary Teacher
_________________________
_______________
Special Subject Teacher
_________________________
_______________
Permit
_________________________
_______________
Life Certificate
_________________________
INSTRUCTIONAL LEVELS PREFERRED
(Mark “1" for first choice, “2" for second choice, etc.)
Grade Level:

____K ____1 ____2 ____3 ____4 ____5 ____6 ____7 ____8 ____9-12 ____ District

________________

SUBJECT IN ORDER OF PREFERENCE:
________________
_________________
_________________

1ST Choice

2nd Choice

3rd Choice

4th Choice

_________________
5th Choice

SPECIAL EDUCATION (CHECK ALL APPROPRIATE AREAS)
_____Emotionally Handicapped
_____Learning Disabilities
_____Physically Handicapped
_____Educationally Handicapped

_____Gifted Talented
_____Speech/Language
_____Psychometrist

____Hearing Impaired
____Visually Impaired
____Psychologist

The Holmes County School District does not discriminate on the basis of sex, race, religion, color, national origin, age or handicap.

Other Professional Areas __________________________________________________________________________________________

College. High School.Include. Post Graduate Work in order taken Dates Attended Degree Received Month & Year Major Subject Minor Subject ------------------------------------------ ------------------------------------------ ------------------------------------------ ------------------------------------------ ------------------------------------------ EXPERIENCE Begin with most recent experience Name and Complete Address of School System ----------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- Period of Service (Exact Month & Year) No. Subject) Reason for Leaving . Graduate.EDUCATION Name of school and location . of Months Nature of Work (Grades.

been discharged._______________________________________________ Date contract ends_________________ What is the earliest you could begin work with our system?_______________________________________________________ Are you a citizen of the United States? _______Yes _______No Have you ever been asked to resign. ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ List college activities and honors before and since graduation. ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ .Have you previously been employed by the Holmes County School District? Are you presently under contract with any school system? _______Yes _______Yes ______No ______No If yes. ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Additional information you wish to submit.__________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Have you ever been convicted of an offense other than a misdemeanor? _______ yes ______ no If yes. explain. what school system. or failed to be re-employed for a teaching or administrative position? ________Yes _______No If yes. explain __________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ List co-curricular activities which you are qualified and prepared to direct.

three (3) reference forms will be given to you. scholarship. STATE. Please read and sign them if in agreement. addresses and telephone numbers must be accurate and complete. principals.662-834-2175. you are encouraged to call the office of Superintendent . and address of three (3) individuals as your references. and supervisors under whom you have worked in addition to college professors and supervisory teachers who have first hand knowledge of your character. ZIP) PHONE NUMBER READ CAREFULLY AND SIGN THE FOLLOWING STATEMENT: By my signature I attest that the information contained in this application is true and represents me accurately. personality. Names.REFERENCES List the names. At the time of your application. NAME OFFICIAL POSITION ADDRESS (ST/PO. Signature ______________________________________________ Date______________________________________ PLEASE NOTE: It is the responsibility of the applicant to provide a complete application and all other required materials to the Office of Personnel. . position. and teaching ability. Failure to provide said application and materials will invalidate the application. All references will be verified. Please do not list relatives as references. CITY. Include superintendents. I understand that this application will remain in the active file for a period of one (1) year and then will be classified as inactive unless I notify the personnel office in writing to keep the application current. I agree to abide by all the policies approved by the School Board and will cooperate fully with inservice programs for professional improvement. If you have questions concerning your application. If employed. titles.