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แบบค ำรองขอยำยผบรหำรสถำนศกษำ สงกดส ำนกงำนคณะกรรมกำรกำรศกษำขนพนฐำน (ตำมประกำศเพมเตม) ยนค ำรองขอยำย วนท. ........................................................... สงกด ส ำนกงำนเขตพนทกำรศกษำมธยมศกษำ เขต 9 ส ำนกบรหำรงำนกำรศกษำพเศษ

ชอ-สกล...............................................................ต ำแหนง.................................วทยฐำนะ……...……….……… โรงเรยน................................................................................สพป./สพม..............................................................ต ำแหนงเลขท.............................รบเงนเดอนอนดบ คศ..........ขน................................บำท (ปงบประมำณ 2556)

กรณ สพท./ส ำนกบรหำรงำนกำรศกษำพเศษ ประกำศต ำแหนงวำงเพมเตม ภำยในเขตพนทกำรศกษำ/ภำยในส ำนกบรหำรงำนกำรศกษำพเศษ ระหวำงเขตพนทกำรศกษำ

ประวตสวนตว ขอมลอน ๆ ขอยำยไปด ำรงต ำแหนงท เหตผลกำรขอยำย 1. เกดวนท........เดอน.......................พ.ศ. ................... 1. ผลกำรปฏบตงำน (ระบ) 1. หนวยงำนกำรศกษำ ..............……………………………….. 2. วฒ........................................................................... ...............................................................................

.................................................................................. ..................................................................................

(1) โรงเรยน............................................................ ............................................................................

………………………………………….

............................................................................... .................................................................................. ............................................................................ .…………………………………………. 3. ควำมรควำมสำมำรถในกำรพฒนำสถำนศกษำ .................................................................................. ............................................................................ ………………………………………….. ................................................................................ .................................................................................. (2) โรงเรยน............................................................ ………………………………………….. ................................................................................ .................................................................................. ............................................................................ ..................................………...………… ................................................................................ .................................................................................. ............................................................................ …………………………………………... ................................................................................ .................................................................................. ............................................................................ …………………………………….......... ................................................................................ .................................................................................. ............................................................................ .…………………………………………. 4. ประสบกำรณ.......................................................... .................................................................................. (3) โรงเรยน............................................................ ………………………………………….. ................................................................................ .................................................................................. ............................................................................ ................................................................. ................................................................................ .................................................................................. ............................................................................ …………………………………………... ................................................................................ .................................................................................. ............................................................................ …………………………………….......... 5. คสมรสชอ............................................................... 2. กำรรกษำวนยและจรรยำบรรณ (4) สถำนศกษำใดกไดทประกำศเพมเตม .…………………………………………. อำชพ....................................................................... เคยถกลงโทษทำงวนย ………………………………………….. ทท ำงำน................................................................... ภำคทณฑ ตดเงนเดอน ลดขนเงนเดอน 2. กรณไดรบพจำรณำใหยำยตำมขอ 1 แลว …………………………………………... ต ำบล....................................................................... เคยถกพจำรณำเกยวกบกำรประกอบวชำชพคร แลว จะไมขอระงบหรอเปลยนแปลงไมวำกรณใด ๆ …………………………………….......... อ ำเภอ...................................................................... ตกเตอน ภำคทณฑ ทงสน .…………………………………………. จงหวด.................................................................... พกใชใบอนญำต เพกถอนใบอนญำต …………………………………………..

-2- 6. ปจจบนอยบำนเลขท............................................ หมท..........ต ำบล................................................. อ ำเภอ.................................................................. จงหวด................................................................. 7. ทอยเมอไดรบยำยแลว......................................... หมท..........ต ำบล................................................. อ ำเภอ.................................................................. จงหวด................................................................. ประวตการรบราชการ 1. เรมรบรำชกำรต ำแหนง........................................ สงกด................................................................... ตงแตวนท.......เดอน..........................พ.ศ. .......... 2. ปจจบนด ำรงต ำแหนง.......................................... สงกด................................................................... ตงแตวนท.......เดอน..........................พ.ศ. .......... 3. เคยลำศกษำตอ (ครงหลงสด) ระดบ.................... สถำนศกษำ......................................................... ตงแตวนท.......เดอน..........................พ.ศ. .......... ถงวนท...........เดอน..........................พ.ศ. .......... 4. รวมเวลำรบรำชกำรทงหมด...............................ป ..................เดอน..............................................วน

3. ปรมาณงานหนวยงานการศกษาปจจบน จ ำนวนบคลำกร............................................คน จ ำนวนหองเรยน..........................................หอง จ ำนวนนกเรยน............................................คน ปฐมวย จ ำนวน...........คน ระดบชน ป.1-6 จ ำนวน...........คน ระดบชน ม.1-3 จ ำนวน...........คน ระดบชน ม.4-6 จ ำนวน...........คน 4. ปจจบนชวยปฏบตราชการท .......................................................................... .......................................................................... .......................................................................... .......................................................................... .......................................................................... .......................................................................... .......................................................................... ......................................................................... ......................................................................... ......................................................................... ตงแตวนท.......เดอน..........................พ.ศ. ..........

หลกฐานประกอบการพจารณา ส ำเนำ ก.พ.7 ส ำเนำทะเบยนบำน ส ำเนำใบส ำคญกำรสมรส ใบรบรองแพทย บนทกประจ ำวน ต ำรวจ/ฝำยปกครอง วสยทศนควำมเปนผน ำ อน ๆ (ระบ)............................................................ ............................................................................... …………………………………………………… …………………………………………………… …………………………………………………… ............................................................................... …………………………………………………… …………………………………………………… …………………………………………………… ............................................................................... …………………………………………………… เบอรโทรศพททสำมำรถตดตอได …………………………………………………… ……………………………………………………..

ความเหนผอ านวยการสถานศกษา .................................................................. ......................................................................... ......................................................................... ......................................................................... ......................................................................... ลงชอ (.......................................................................) ต ำแหนง........................................................... ควำมเหนผอ ำนวยกำรส ำนกงำนเขตพนทกำรศกษำ ............................................................... ......................................................................... ......................................................................... ......................................................................... ลงชอ (.......................................................................) ต ำแหนง...........................................................

ขอรบรองวำขอมลถกตองและเปนควำมจรง ลงชอ...................................................................................ผขอยำย

(.........................................................................) วน................เดอน..........................................พ.ศ. .............