BARR REEVE COMMUNITY SCHOOLS

P. O. Box 97

Montgomery, IN 47558

(812) 486-3220

APPLICATION FORM – CERTIFIED EMPLOYEES

NAME________________________________________________________________________

(last) (first) (middle)

TEMPORARY ADDRESS PERMANENT ADDRESS

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Telephone: (____)__________________ Telephone: (____)_____________________

TEACHING CERTIFICATE:

Subjects or grades certified to teach:________________________________________________

Kind of certificate:____________________________________ Valid in Indiana?:___________

Serial Number:_______________________________________ Expiration Date:____________

Remarks:______________________________________________________________________

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TEACHING PREFERENCE:

A. Elementary – List in order of grade preference.

1.______________________ 2.______________________ 3.______________________

B. Secondary – List subjects in which you are licensed.

1.______________________ 2.______________________ 3.______________________

C. Other (Music, Art, Physical Education, Etc.) List grade level or preference.

1.______________________ 2.______________________ 3.______________________

PLEASE INDICATE:

Substitute: _____Elementary _____High School _____Junior High _____All Grades

Regular Contract:__________________ Date Available for Employment:__________________

REFERENCES:

Give individuals who can speak with authority of your preparation and experience (no relatives).

Name Phone Number Address Occupation

TRAINING (Secondary Teachers only):

Major Subject Fields (at least 40 semester hours):

1._____________________________________ 2._____________________________________

Minor Subject Fields (at least 24 semester hours):

1._____________________________________ 2._____________________________________

Extra-Curricular Activities you can direct:

1._____________________________________ 2._____________________________________

Check areas that you are certified to teach and sports that you are willing to coach.

ARTS AND CRAFTS HOME ECONOMICS SCIENCE

_____Elementary Arts _____Clothing and Textiles _____Advanced Biology

_____Ceramics _____Consumer and Family _____Astronomy

_____Graphics Economics _____Biology

_____Metals _____Foods and Nutrition _____Chemistry

_____Painting _____Human Development _____Earth Science

_____Sculpture _____Home Management and _____Environmental Science

_____Weaving Housing _____Physical Science

_____Physics

BUSINESS INDUSTRIAL ARTS

_____Accounting _____Drafting and Planning SOCIAL SCIENCE

_____Clerical Practice- Office _____Electricity-Electronics _____Anthropology

Procedure _____General Shop-Junior High _____Citizenship

_____Data Processing Fundamentals _____Metals _____Economics

_____Distributive Marketing _____Power Mechanics _____Geography

_____Employment Preparation _____Woods _____Government

_____World of Construction _____Psychology

COACH _____World of Manufacturing _____Sociology

_____Baseball _____U.S. History

_____Basketball LANGUAGE ARTS _____World History

_____Cross Country _____English

_____Football _____Developmental Reading SPECIAL EDUCATION

_____Golf _____Dramatics _____Emotionally Handicapped

_____Softball _____Journalism _____Learning Disabilities

COACH (cont’d) LANGUAGE ARTS (cont’d) SPECIAL EDUCATION (cont’d)

_____Track _____Publications _____Mildly Mentally Handicapped

_____Volleyball _____Speech _____Moderately Mentally

Handicapped

MUSIC MATHEMATICS _____Physically Handicapped

_____Band _____Advanced Math _____Severe and Profound

_____General _____Algebra I _____Speech and Hearing

_____Instrumental _____Algebra II _____Visually Handicapped

_____Orchestra _____Math Problems

_____Vocal _____Geometry SPECIAL AREA

_____Junior High School _____Guidance Counselor

PHYSICAL EDUCATION _____Pre-Calculus _____Library Science

_____Elementary _____Calculus _____Psychometrist

_____Junior High

_____Senior High FOREIGN LANGUAGE

_____Driver Education _____French

_____Health _____Spanish

Other areas not mentioned (please list):__________________________________________________________________

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GIVE EDUCATION ABOVE NINTH GRADE THROUGH COLLEGE:

Name of Institution Location Dates Attended Total Year Degree

City & State from to Years Graduated

TEACHING EXPERIENCE:

List all previous school corporations at which you have taught in descending order from most recent.

Employing School Corporation No.of From To Teaching Reason for

Name and Address years mnth/yr mnth/yr Assignment Leaving

PROFESSIONAL STATUS:

Have you ever been terminated from a teaching position or asked to resign by a school employer?

_______Yes _______No

If Yes, please explain (Attach additional sheets if necessary):_________________________________________

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If you are registered with a college placement office, please give name of college and address:

Name of college: ___________________________________________________________________________

Address: __________________________________________________ Phone: _______________________

Is there any reason that you cannot perform the responsibilities and duties of a teaching position during the next

year? _______Yes _______No

If yes, why? _______________________________________________________________________________

__________________________________________________________________________________________

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Indicate your beliefs about public schools and what you would contribute to students if you were selected as a

member of the Barr-Reeve Community School Corporation.

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AUTOBIOGRAPHICAL STATEMENT

Write a full statement concerning your early environment, travel, military experience, experiences outside of school

which may affect teaching, extra-curricular participation, cultural and vocational interests and any unique

qualifications which may distinguish you from candidates with otherwise similar qualifications.

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BACKGROUND INFORMATION STATEMENT

AND RELEASE OF CLAIMS

Read this entire document carefully and do not sign it unless you understand and agree to each of its provisions.

1. GENERAL INFORMATION:

Employment with the Barr-Reeve Community School Corporation requires continued compliance with established standards of

conduct. These standards are based upon the School Corporation's duty to protect its students and employees and provide and

example of acceptable adult behavior for its students.

The information provided in this statement is an important part of your application for employment. Any material omission in it

will disqualify you from further consideration for employment or termination if you are employed.

Arrests, criminal charges and convictions will be considered based upon established administrative guidelines and qualification

standards and essential functions of the position applied for. A copy of the administrative guidelines on the use of this

information is available to you upon request. An affirmative answer to a question in this background statement will not be an

automatic bar to employment.

If you have any doubt about whether a particular incident or circumstance should be fully disclosed in this statement, you should

error in favor of disclosing and explaining the circumstance.

2. PRE-EMPLOYMENT QUESTIONS:

Please answer each of the following questions completely and accurately. Attach and label separate sheets of paper necessary to

answer each question.

Has your conduct ever been subject of an investigation into a violation of state or federal law? No Yes.

If yes, please explain fully and provide names of persons involved, dates and the status of any matter.

For the purpose of this questions, "state or federal law" includes laws prohibiting violation of civil rights, discrimination based

on gender, race, disability, religion, or national origin and harassment based on these characteristics.

Have you ever been arrested for, charged with, indicted for or convicted of a crime? No Yes. If yes please

provide the following for each incident on a separate sheet: What was alleged? By Whom? Who investigated? What was the

result of the investigation?

Has there ever been a finding by a court or administrative agency that you have violated a state or federal civil rights law in the

course of employment?

No Yes. If yes, please describe each situation fully on a separate sheet.

I AFFIRM UNDER PENALTY OF PERJURY THAT INFORMATION PROVIDED BY ME IN RESPONSE TO THESE PRE-

EMPLOYMENT QUESTIONS IS TRUE AND COMPLETE.

Signature Date

3. AUTHORIZATION TO OBTAIN INFORMATION:

In exchange for the consideration of my application for employment by the Barr-Reeve Community School Corporation, I

authorize the Superintendent of the School Corporation or his/her designee to investigate my background and employment

history including by not limited to inquiring as to my performance on prior jobs, reference checks and obtaining limited criminal

history and driving history information.

I authorize my former employers, supervisors, my references and local, state and federal law enforcement agencies to cooperate

in providing this information. I also agree to cooperate fully as necessary to obtain this information.

Signature Date

4. WAIVER OF CLAIMS:

In consideration for the consideration of my application for employment by the Barr-Reeve Community School Corporation, I

acknowledge the legitimate business need for the Barr-Reeve Community School Corporation to fully investigate my

background and employment history in the process of the consideration of my application for employment. I also acknowledge

the importance of the full and truthful participation of those persons having information about my background and employment

history in this process.

I therefore release the Barr-Reeve Community School Corporation and those providing truthful information in this process, as

well as their agents, officers, attorneys, and employees in their official and individual capacities, from any and all claims,

demands, liabilities and causes of actions including but not limited to a claim for defamation, slander, libel, and invasion of

privacy except to the extent that they have intentionally provided false information or represented un-investigated information as

verified.

THIS DOCUMENT CONTAINS A WAIVER OF CERTAIN TYPES OF CLAIMS THAT MAY NOW EXIST OR MAY

LATER ARISE AGAINST PERSONS AND ORGANIZATIONS INVOLVED IN THE INVESTIGATION OF YOUR

BACKGROUND. DO NOT SIGN THIS DOCUMENT IF YOU DO NOT UNDERSTAND IT OR DO NOT MEAN TO

AGREE TO IT IN ALL RESPECTS.

Signature Date

It is stated policy of the Barr-Reeve Community School Corporation not to discriminate on the basis of race, color, religion,

national origin, sex, or handicaps.

I hereby affirm that the statements made in this application are true to the best of my knowledge and belief. I understand that

future employment may be terminated if I willfully misrepresented information submitted.

Signature Date

MEMO TO: BUS DRIVERS, COACHES, & NEW EMPLOYEES FROM: BARR-REEVE SUPERINTENDENT’S OFFICE DATE: NOVEMBER 3, 2011 SUBJECT: EXPANDED CRIMINAL HISTORY POLICY/E-VERIFY/FORM I-9

Indiana State Law now requires all school corporations to obtain for each individual hired for employment that is likely to have direct, ongoing contact with children, as a result of the individual’s position, to have an Expanded Criminal History check, Employer Verification (E-VERIFY and FORM 1-9 completed. Prior to beginning employment with Barr-Reeve Community Schools, Inc., you need to fill out the proper forms online so that Safe Hiring Solutions can conduct an Expanded Criminal History Check for you. As a part of that process, you will need to electronically sign a notice and authorization form consenting to this check. This authorization form will allow Safe Hiring Solutions LLC, to verify the information you provide and share its results with Barr-Reeve Community Schools. The questionnaire takes approximately 20 minutes to complete and we recommend that you double check the information you provide to ensure there is no delay with beginning your employment. The cost is $28.00 for the Expanded Criminal History check and this must be paid by the prospective employee. An associate from the Safe Hiring Solutions may contact you for additional information during the verification process. Please respond promptly so the background verification can be completed as quickly as possible so as not to delay the hiring process. If you need any assistance while filling out the application you may contact the Barr-Reeve Schools Administrative Office at 812-486-3220 or email Tamara Swartzentruber @ tswartzentruber@barr.k12.in.us or our background agency, Safe Hiring Solutions at 317-745-6945 or email info@safehiringsolutions.com. An order summary page will confirm the information that you have submitted allowing you to review your order and make any necessary changes. Please be careful to double check all the information you provide. Once you place the order you will not be able to modify or change it. The Expanded Criminal History background check must be completed on the Barr-Reeve Community Schools website www.barr.k12.in.us under Corporation and then employment. Click on the Safe hiring Solutions link. Please contact Tamara Swartzentruber at the central office 812-486-3220 when you have completed the request for the background check. Attached to this form is information regarding E-VERIFY and FORM I-9

CRIMINAL HISTORY POLICY

To help ensure a safe environment and as required by state law, the Barr-Reeve School

Corporation will obtain for each individual hired for employment that is likely to have direct,

ongoing contact with children as a result of the individual’s position an expanded criminal history

check. The expanded criminal history check will be obtained by the Corporation prior to the

individual’s employment but no later than three (3) months after the individual’s employment

begins. The individual will be responsible for the cost to the School Corporation for obtaining the

expanded criminal history check.

Each individual hired may be questioned about the individual’s expanded criminal history

check. Failure to answer honestly any questions related to the expanded criminal history check

may be cause for termination of the applicant.

Any information obtained from any type of criminal history check is confidential and shall not be

released or disseminated.

All school employees and individuals or entities that have contracts for services with the

Corporation are required by state law to report convictions of certain crimes enumerated in state

law to the Corporation. The superintendent or designee is responsible for implementing

regulations to notify the employees, including volunteers, and entities for contracted services

of this duty.

LEGAL REFERENCE: I.C. 20-26-5-10

I.C. 20-26-5-11

FROM: ADMINISTRATION OFFICE

SUBJECT: DIRECT DEPOSIT INFORMATION

DIRECT DEPOSIT WILL BE IMPLEMENTED FOR ALL EMPLOYEES. WE WILL BE NEEDING YOUR

INFORMATION AS TO THE BANK YOU WANT YOUR PAY DEPOSITED INTO. ATTACH A VOIDED

CHECK (DO NOT USE A DEPOSIT SLIP AS THEY ARE SOMETIMES DIFFERENT NUMBERS THAN

A VOIDED CHECK) AND A SEPARATE FORM FOR EACH BANK ALONG WITH AMOUNTS AND

RETURN IT TO OUR OFFICE AS SOON AS POSSIBLE. ADVANTAGES OF DIRECT DEPOSIT: -NO LOST CHECKS -MONEY USUALLY DEPOSITED BY THURSDAY AFTERNOON OR PAY WEEK -YOU MAY DESIGNATE THE BANK OR CREDIT UNION OF YOUR CHOICE -YOU DO NOT HAVE TO WAIT FOR THE MAIL DELIVERY OF 2 OR 3 DAYS AUTHORIZATION AGREEMENT FOR DIRECT DEPOSIT: BARR-REEVE COMMUNITY SCHOOLS I hereby authorize Barr-Reeve School Corp., hereinafter called Company, to initiate credit entries to my account indicated below and the depository named below, hereinafter called Depository, to credit the same to such account. NAME(S) ON ACCOUNT: _________________________________________________________________ ADDRESS: ____________________________________________________________________________ CITY: __________________________________________ STATE: ____________ZIP CODE: ___________ NAME OF BANK: ______________________________________________________________________ TYPE OF ACCOUNT: CHECKING________ OR SAVINGS________ BANK TRANSIT/ABA ROUTING #:__________________________________________________________ BANK ACCOUNT #: _____________________________________________________________________ CHECKING: __________________________________ SAVINGS: ________________________________ AMOUNTS: WRITE “FULL” OR “REMAINDER” IF USING MORE THAN ONE ACCOUNT

The authorization is to remain in full force and effect until company has received written notification from me of its termination in such time and in such manner as to afford Company and Depository a reasonable opportunity to act on it. NAME: _________________________________________ SOCIAL SECURITY #: _____________________ PRINTED NAME

DATE: _______________________ SIGNATURE: ___________________________________