Personal Data

*Name (last, first, middle):

Present Address:

*Number and Street:

*City:

*State:

*Zip:

*How long have you resided there?

Previous Address:

Number and Street:

City:

State:

Zip:

How long have you resided there?

*Telephone Number:

*Are you over the age of 18?

If no, employment is subject to verification that you are of minimum legal age:

Employment Objective

*Position Desired:

*Salary Desired:

*Location:

General Information

*How were you referred to us?

If you were referred by an employee, please list their name and location:

*Have you ever been employed by Imagine Schools, Inc., Chancellor Beacon Academies, Inc., Chancellor Academies, Inc., Beacon Education Management and/or JCR and Associates?

If yes, please list dates of employment.

From:

To:

*Have you ever been employed under any name other than the one stated in this application?

If yes, please provide the other name(s):

*Do you have any relatives or friends employed by Imagine Schools?

If yes, please provide their name, relationship and location of employment:

*Are you presently employed?

If yes, what notice will be required?

*What date will you be available for employment?

*Have you ever been involuntary terminated, not re-appointed or asked to resign from a previous job?

If yes, please explain:

Certification

*Do you hold an Educator's Certificate?

If yes, please provide the following:

Certification Type 1:

Valid from 1:

Valid to 1:

Issuing State 1:

Subject, area or coverage 1:

Certification Type 2:

Valid from 2:

Valid to 2:

Issuing State 2:

Subject, area or coverage 2:

If you do not hold an Educator's Certificate, are you eligible to receive one?

Please explain:

*Have you ever had an Educator's Certificate suspended, revoked or not re-issued?

If yes, please explain:

Education Record

*High School Address (City/State):

*High School Years Completed:

*High School Major Field of Study:

*High School Graduated:

*High School Degree:

College 1 Address (City/State):

College 1 Years Completed:

College 1 Major Field of Study:

College 1 Graduated:

College 1 Degree:

College 2 Address (City/State):

College 2 Years Completed:

College 2 Major Field of Study:

College 2 Graduated:

College 2 Degree:

Graduate School Address (City/State):

Graduate School Years Completed:

Graduate School Major Field of Study:

Graduate School Graduated:

Graduate School Degree:

Trade/Correspondence School Address (City/State):

Trade/Correspondence School Years Completed:

Trade/Correspondence School Major Field of Study:

Trade/Correspondence School Graduated:

Trade/Correspondence School Degree:

Other Address (City/State):

Other Years Completed:

Other Major Field of Study:

Other Graduated:

Other Degree:

*List academic honors, scholarships, and honorary fraternities:

*List hobbies and outside interests:

*Do you plan to continue your education?

If yes, please specifiy:

Foreign Languages

Language 1:

Indicate degree of fluency 1:

Read Write Speak

Language 2:

Indicate degree of fluency 2:

Read Write Speak

Business Skills

*Typing Speed:

*Word Processing:

*Shorthand:

*Dictaphone:

*Computer Hardware/Software:

Other Business Equipment:

*List any professional licenses you hold other than teaching certificates:

*List any professional organizations you belong to:

Military Service

Branch:

Highest Rank Attained:

Dates of Service:

Special Training:

Did you receive anything other than an honorable discharge?

Criminal Record

Answering "yes" to these questions does not constitute an automatic bar of employment. Only those crimes which are substantially related to the position you are seeking will be considered.

*Have you ever been convicted, pled no contest, been placed on probation, enrolled in a pre-trial diversion program, or had adjudication withheld in a criminal offense, felony, misdemeanor or otherwise?

If yes, please give dates and details for each instance:

*Do you have any criminal charges currently pending?

If yes, please explain:

Employment History (complete in full - do not attach a resume)

Please list below all present and past employment since graduation, including at least three past employers, for the last ten years.

Dates of Employment 1:

Total Month 1:

Reason for Leaving 1:

Name of Employer 1:

Type of Business 1:

Address/City/State/Zip 1:

Phone 1:

Starting Position 1:

Supervisor's Name, Title & Phone 1:

Starting Salary 1:

Most Recent Position 1:

Supervisor's Name, Title & Phone 1:

Ending Salary 1:

May we contact? 1:

If not, why not? 1:

Give full description of responsibilities and duties 1:

Dates of Employment 2:

Total Month 2:

Reason for Leaving 2:

Name of Employer 2:

Type of Business 2:

Address/City/State/Zip 2:

Phone 2:

Starting Position 2:

Supervisor's Name, Title & Phone 2:

Starting Salary 2:

Most Recent Position 2:

Supervisor's Name, Title & Phone 2:

Ending Salary 2:

May we contact? 2:

If not, why not? 2:

Give full description of responsibilities and duties 2:

Dates of Employment 3:

Total Month 3:

Reason for Leaving 3:

Name of Employer 3:

Type of Business 3:

Address/City/State/Zip 3:

Phone 3:

Starting Position 3:

Supervisor's Name, Title & Phone 3:

Starting Salary 3:

Most Recent Position 3:

Supervisor's Name, Title & Phone 3:

Ending Salary 3:

May we contact? 3:

If not, why not? 3:

Give full description of responsibilities and duties 3:

Please explain any gaps in your employment history:

Previous Experience

*Please describe any previous experience that you have in the position for which you are applying, or in any similar or related position:

References

Please list three (3) individuals not related to you, whom you have known for at least one year, and who have observed your work performance (supervisors or employers, not co-workers).

Name 1:

Relationship 1:

Occupation 1:

Phone Number 1:

Years Known 1:

Name 2:

Relationship 2:

Occupation 2:

Phone Number 2:

Years Known 2:

Name 3:

Relationship 3:

Occupation 3:

Phone Number 3:

Years Known 3:

Name 4:

Relationship 4:

Occupation 4:

Phone Number 4:

Years Known 4:

Emergency Contact

In case of accident or other emergency, whom should we contact?

*Name:

*Relationship:

*Home Phone:

*Cell Phone:

*Address (Number and Street):

*City:

*State:

*Zip:

*Place of Work (including address):

*Work Phone: