Join Our Team of Licensed Educators!

Personal Information

First Name *

Last Name *

Address 1 *

Address 2

City *

State *

Zip Code *

Phone *

Email Address *

Position Applying For *

Date available *

Are you a citizen of the US? *

Yes

No

If no, are you authorized to work in the US? *

Yes

No

Have you ever worked for the Washburn School District before? *

YES

NO

If yes, when?

Are you currently licensed to teach in North Dakota? *

YES

NO

If yes, ND License #

List any specific credentials, endorsements, certifications, trainings, and licenses you currently hold. *

Education

High School *

HS Address *

Dates attended *

Did you graduate? *

YES

NO

College *

College Address *

Dates attended *

Did you graduate? *

YES

NO

Degree *

Other

Address

Dates attended

Did you graduate?

YES

NO

Degree

Teaching Experience/Student Teaching Experience

Employer 1

Company Name

Address

Phone

Start Date +

End Date +

Position

Salary

Supervisor/Manager

Reason for Leaving

May we contact?

Yes

No

Phone Number

Employer 2

Company Name

Address

Phone

Start Date +

End Date +

Position

Salary

Supervisor/Manager

Reason for Leaving

May we contact?

Yes

No

Phone Number

Employer 3

Company Name

Address

Phone

Start Date +

End Date +

Position

Salary

Supervisor/Manager

Reason for Leaving

May we contact?

Yes

No

Phone Number

Other Work Experience

Employer 1

Company Name

Address

Phone

Start Date +

End Date +

Position

Salary

Supervisor/Manager

Reason for Leaving

May we contact?

Yes

No

Phone Number

Employer 2

Company Name

Address

Phone

Start Date +

End Date +

Position

Salary

Supervisor/Manager

Reason for Leaving

May we contact?

Yes

No

Phone Number

Employer 3

Company Name

Address

Phone

Start Date +

End Date +

Position

Salary

Supervisor/Manager

Reason for Leaving

May we contact?

Yes

No

Phone Number

References

Reference 1

Name *

Title *

Email Address *

Phone *

Reference 2

Name

Title

Email Address

Phone

Reference 3

Name

Title

Email Address

Phone

Military Service

Branch

Dates Served

Rank at Discharge

Type of Discharge

If other than honorable, explain

Additional Skills

List any additional skills that you would like to mention.

Why do you want to work at the Washburn School?

Activities, clubs, and organizations you can coach or supervise

Professional activities, organizations, awards, and interests

Personal interests, hobbies, and relevant experiences

Please Answer the Following Questions

Answer YES or NO to the following Questions *

Are you able to perform the essential functions of the position for which you are applying?
Are you presently under contract?
In the answer to #2 is Yes, is your employer aware that you are seeking this position?
Have you ever been on an improvement plan or placed on probation?
Have you ever been the subject of a complaint to or investigation by the Education Standards and Practices Board or any other licensing board, or had your license suspended or revoked?
Have you ever resigned or otherwise separated from any employment (inclusive of regular or extracurricular positions) in order to avoid discharge or nonrenewal?
Have you ever been dismissed, discharged, fired, or forced to resign from any employment?
Have you ever resigned or otherwise left any employment while allegations of misconduct were pending?
Have you ever been disciplined by a past or present employer because of allegations of misconduct?
Are you presently charged with, but not convicted of, a crime? (Exclude civil infractions, such as minor traffic citations.)
Have you ever been non-renewed from any employment (inclusive or regular or extracurricular positions)?
Have you ever pleaded guilty or been convicted of any felony crime involving the physical injury or death of a child, promoting prostitution of a minor child; assault; incest; child abuse or neglect; custodial interference; child molestation; promoting pornography; selling or distributing erotic material to minors; criminal mistreatment; violation of a child abuse restraining order; or child abandonment? (The term "convicted" means all adverse dispositions, including a finding of guilty, a plea of guilty or nolo contendere, an Alford plea, a stipulation to the facts, a deferred or suspended sentence, or a deferred prosecution.)
Have you ever pleaded guilty to, or been convicted of one of the following crimes against persons: aggravated murder; first or second degree murder; first or second degree kidnapping; first, second, or third degree assault; rape or statutory rape; first or second degree arson; burglary, manslaughter or extortion; indecent liberties or decent exposure; communication with a minor for immoral purposes; sexual exploitation of a minor or developmentally disabled person; been found by a court in a protection proceeding to have abused or financially exploited a vulnerable adult; criminal mistreatment; violation of a child abuse restraining order; or child abandonment?
Within the past seven (7) years, have you pleaded guilty to, been found guilty of, or forfeited bond regarding violation of any city or county ordinance or state law or regulation involving physical threat, injury or abuse of a victim who was then under the age of 18?
Have you ever been found in any dependency action under RCW 13.34.030(2)(b); been found guilty by a court in a domestic relations proceeding under Title 26RCW; or been found guilty in any disciplinary board final decision to have sexually assaulted or exploited any minor or to have physically abused any minor?
Have you ever plead guilty or been convicted of a misdemeanor or felony not listed above?

If you answered YES to any of the preceding questions, please provide an explanation or comment?

Disclaimer and Signature

People of disability may request reasonable accommodation in the hiring process by contacting the Superintendent; 713 7th St., PO Box 280; Washburn, ND 58577, or by calling (701) 462-3221.

The Washburn School District is an equal opportunity employer and subject to veteran’s preference laws. It also a drug-free, tobacco-free educational system. A criminal history background check is required prior to employment. The background check will be requested by the Washburn School District or the Education Standards & Practices Board, or both. The District employs only U.S. citizens and lawfully authorized
non-U.S. citizens. All new employees must show employment eligibility verification as required by the U.S. Immigration and Naturalization Service.

I waive my right of access to any such information, and without limitation hereby release the school district and the reference source from any liability in connection with its release or use. Furthermore, I certify that I have made true, correct and complete answers and statements on this application in the knowledge that they may be relied upon in considering my application. I understand that any omission, false answered
statement made by me on the application, or any supplement to it will be sufficient grounds for failure to employ or for my discharge should I become employed with the school district.

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Print Name *

Date *

Signature *

clear

▪ This application may be submitted by mail, in person, or electronically. To submit by mail, send to Superintendent; Washburn Public School District; PO Box 280; Washburn, ND 58577. To submit electronically, email as an attachment to penny.hetletved@k12.nd.us or HIT SUBMIT on this form.
▪ You may include a cover letter and and a resume.

Please submit a cover letter

Please submit a copy of your resume.

References

Transcripts