ADDITIONAL(REQUIREMENTS((

1. Harlan(Elementary(Principal(application(must(include(Resume.((

2. Three(Work<Related(references(must(be(returned.(This(is(in(addition(to(the(3(recommendation(pages(that(accompany(the(application.((On(the(references(a(name,(

address,(and(phone(number(must(be(included.(If(your(references(are(those(listed(on(

the(recommendation(pages,(contact(information(must(be(included(so(that(we(can(

communicate(with(all(references.(

(

(

Please(make(a(selection:(

May(we(contact(your(current(employer?(_____Yes( ( ______No(

(

Signature:(_______________________________(

(

Date:(___________________________________(

(

(

(*(Please(be(aware(that(Harlan(Independent(reserves(the(right(to(perform(Internet(based(research(on(all(applicants.(

(

(

Return(this(document(with(you(application.(

HARLAI{ INDEPENDENT SCHOOL DISTRICTINFORIVIATION FOR APPLICAITTS FOR

TEACHING POSITIONS

we-lPPreciate your interest in obtaining a tedfiing position with us. This is howapplications are handled:' :

lr- Ify:.u.u*-applyrng for a specific *1*n *r"d in the Job Register,vour application will be filed ina-folder for that p"rir,i"" ci,i*,i.i,iiii t p*"0based on your certificatioq in one of thetto"" gneJiou"o; secondary, elementary, orspecial edrcation Each time that a position opi*, * *iu ,"ui"; rh;il;;;;r" forderand transfer all rer,evagappricatiors to tt" oto"rio, tt"tlob. Except inimergencysituations' we willnotp-6" tbat you are bemg.o*lo"*t-for this position to *" ifyouare still interested in a job with us and so thut iou.- *ppry any additionaldocumentation needed

2' onor immediatelyd":* date rygified inthe Job Register, the searchcomrdttee will review applications and select .-iria"t* t" ue intervieilJ.

-bouo*log

completion ofthe inte'r:niewprocess, the search comminee wrr forward itsrecommendations to the superi*endent who will r"d G zurJ*iri"Jnppfcantswill be notified by -arl tt,ut tn"ir.ppri.ation has been reviewed

3' Exclnt in e*enrating circumstanceq the following information should beon file in the office by the closing aiefrr apfications.- --'

a photocopy ofteaching certificate or statement oferigibilityB. Transcripts from all.iU"go attendedc' sanple lessonpranpr.p"ia *"o,uiog to our directionsD' Reco--endatibn fo'd completed uy-tt " ."e'.o",

4. The drstrict bas its own recod*endation frrm. prease bave theeirdividuals who 1 }1|11r

witn your profasionat qru,liicatlons and work to comFlglsthen and mqil the'4 directly to 's.

5. you 11

welcome-to provide us with a rcsume and to barae collegeplacement service send us yo* n" ,[ raauonal hs;;G u* &is is not requiredunless specifically r.q*st"d by the ,**h ;rril;. *rrvrr

6' The fi$ng year for applicaions nrns from the beginning of one school yearto the begiDning of Se o*L at t#ti-" all_applicatio;; unsferred to the lnactivefile except those rrnder active "o*la"*tloo roiliol*ffition Applicanrs wishing toreactivate their file should coffact rhe personnel *;t"ry f"r instnrctions.

I{ARLAI.I II{DEPE}IDENT SCHOOL D I STRICT

INSTRUCTIONS FOR LESSON PLAI.IS REQUIRED

OF THE TEACHER APPLICA}.ITS

To the Appticant

As part of tbe proc!ss hr screeoing applicants forteaching positions, we ask applicants to

subn:it a lesson plan which they actually taught ifttre classroorn. This lesson shoutd be

one designed by you which reflects your own work. Should you be called for an

interview, this tesson plan will be used as a starting pciint for discussing instruction. It

should exemptify your educational philosophy and approach to teaching.

The points to be included are:

l. Course data (Name of course, grade level of studentg number of studentst

length of class perid, any other pertinent data about class needed to interpret the

lesson.)

', 2. CroalJobjectives of tbe lessoa

3. Rctationships of this lcsson to r uoit or sequeoc! of,wort- (Wbat cart! befure

and what w8s to come n!xt.)

4. I-csson development. -

' how the lesson opcned' stepJactivities used in dcvdoping thc lcssoo' bow lesson ctosod

5. Foltow-up. (Related homework if any, how lesson was followed up the noit

day druing thc week.)

6. Evahntion (llow snrderit learoittg was evaluated urd whcc)

Pteasc give enough detait on each of thesc points that we m8y trc able to pictr'[e how tbc

lesson *as condtraed. Ifyor bave on flc i aaaited plur for this lessoq you m8y srbmit il

and anach an addendum which @vers any points not included in your origind plan.

t

t {t-.x;HfF\rf:iNfl:13*,irjfF,{E.e?ad}}l+\E!i\-:ra;F4:I4qsErF!"{l{*!iy.lttst{\\'.r"r+i.aET-\3lrr.,;F}rr1:q* {i .+,,

FIARI-AI\ INDEPENDENT SCHOOL DISTRICT420 EAST CENTRAI STREET - HARLAN, KENTUCKY 40831,-2312

TELEPHONE (606) s73-8700 . FAX (606) 573-8711,

An Equal Edacational and Emphyment Opportunities Institution

APPLICATION FOR A CERTTFTCATED POSITION

NAME (Last / First / Middle) SOCIAL SECURIW NO. DATE

CURRENT ADDRESS PERMANENT ADDRESS (lf Different)

PHONE (Day) PHONE (Evening)

POSITION FOR WHICH APPLYING JOB NUMBER

lf you are not applying for a specific opening, please indicate below the kind of position in which you would be interested:

JOB TITLE SCHOOL GMDE(S)

1 .

2.

3.

CE RTIFI CATI ON INFOR]VIATI ONEnclose a photocopy of your certificate or statement of eligibility with this application.

STATE NO. RANK

CODES CERTIFICATION AREAS EFFECTIVE EXPIRES

A picture lD must accompany this application.

WORK HISTORYGive a complete record of full and parttime employment including non-teaching jobs. Give most recent employer first.

SchoolBoard or Firm PhoneAddressDates of Employment (Monthffear): From toJob Title/Duties

Name of SupervisorReason for LeavingMaywecontactthisemployer? [ Yes tr No (Givereason: )

SchoolBoard or Firm PhoneAddressDates of Employment (Monthffear): From toJob TitlelDuties

Name of SupervisorReason for Leaving

Phone-

Maywecontactthisemployer? E Yes tr No (Givereason: )

School Board or Firm PhoneAddressDates of Employment (Monthffear): From toJob Title/Duties

Name of Supervisor Phone-Reason for LeavingMaywecontactthisemployer? n Yes D No (Givereason: )

School Board or Firm Phone-AddressDates of Employment (Monthffear): From toJob Title/Duties

Name of SupervisorReason for LeavingMaywecontactthisemployer? [ Yes f] No (Givereason: )

SchoolBoard or FirmAddress

Phone

Dates of Employment (Monthffear): From toJob Title/Duties

Name of SupervisorReason for LeavingMaywecontactthisemployer? E Yes tr No (Givereason: )

EDUCATIONAL HISTORYList postsecondary institutions attended starting with the one most recently attended.

SCHOOL LOCATION DATES MAJOR MINOR DEGREE

Forthistypeof employment, State Law requiresa FederalCriminalHistory BackgroundCheckasaconditionof employment.Undercertain circumstances, a NationalCriminalHistory Background Checkmaybe requiredas acondition of employment.(KRS 160.380)

List ALL states of former residence, including the dates of residency. (KRS 160.380)

Total years of teaching experience in public schools___

Will you perform extra duty work? [ Ves n ruo

Do you have any special talents, skills, or expertise which would be useful either in carrying out your professionalduties or in helping with extracurricular activities?

Have you ever had a teaching certificate revoked by any state?lf yes, give details:

fl ves [ ruo

Have you ever been convicted of a felony which has not been annulled, expunged, or sealed by a court? (Kentuckys_choollawdoesnotpermitthehiringofpersonswitharecordofviolentoffensesorsexcrimes.)

[Ves n ruolf yes, describe in full:

I hereby declare that the information provided by me in this application is true, correct, and complete to the bestof my knowledge. I understand that if employed, any misstatement or omission of fact on this application shallbe considered cause for dismissal.

Signature

REFERENCES

Give the names of three persons who would be able to describe your professional qualifications and fitness torthis position.

- Office Use Only

n """ n"o

It references were contacted by phone, give names of those contacted and dates:

.:.....

t Offered position: Acepted: f1""" f] "on""" [ "oDate applicant notified in writing as to action:

Notes;

, ]I

J & R Printing Co. - loyall, l(Y. HISD-ACP - Rev. 05O5 I:iI

Date appliation reviewed: forJob No._

lnvited for interuiew:

Date of interuiew:

HARLAN INDEPENDENT SCHOOL DISTR.ICT420 EAST CENTRAL STREET - HARLAN, I(ENTUCKY M3T.2312

TELEPHONE (606) 573-8700

An Equal Educational and E^p6y^ent Opportunities Instittltoa

REC OMMENDATIOT{ FOR CERTIFICATED POSITIOF{

has $ven your name as a reference in support of

his/her apptication

this form and return

for the position of Grades-. Please cbmplete

it by to the Teacher Search Comminee at the address given above.

CANDI DATE APPRAISAL CH ECKLIST

^9*, on No. 7 (Eementary cardirates only): Are trere any ontent areas ln whi$ Ute candi@te b ercepthnalfy wenpreparod?f{oticeably weak? please erplain.

, l gtft8 / l< r / q

t 8-"-/

I E/EF/< /

i /o t

Please rate the candidate on each item below by ptacing an X in the appropriatebox. lf you do not have a basis for evaluating a particular statement, draw aline across f/re boxes. lf you would tike to comment on a particular rating,please use the space on the back under No. 4 or attach a separate slreet

1. Commr.rnicates effeAively in geaking and writing.

2. Works effeaively wih ofrer people.

3. ls deoend:ble.

4. AccepB resporsibillty br hMer actions.

5. Shotvs inithlive and leaderstrp irn canying out hMerduties

6. Exhibib r:rdeaEnding of ard empatry br studenrs.

7. ls kro,vledgeable in hMercontent area(s). -

8. Uses mefiods wiri'dr reflect loow{edge of ament educational researdr.

9. Demonstrates ability b phn effectivef for instuction.

10. Canies out lnstuction effecfively.

L$F a multisensory appmadt to teadring. induding hardsqr activiti,es where appopriate.

12 Manages chssroom time effectivety b acfiieir! a high lanl of llme on Esk br instrrtion.

13. Dernonstrates abi|rty b cmtd stldent betravbr ard tc employ eflectively pcitive medlods of disciptine.

14. Hardes required paperrrort h an efficient ard timely rnarner.

15. Oemonstrates a ssris d pofessirnal ethics ard persoral integify.

16. Demonsrates a will&qness b go beyond tre call of duty,

| 7. Dernonsfates an urderstandlng of arrd a @rnmit[n!nt t fie teaching pofessbn.

1. How long hare you knorrrn the !ndidate and in what posnion?

2' What clr you consider this p!rson's strengths as a te.ehea4n

q'.

3' Do you have any resenrations about this person's abilig or frtness for this job? lf so, ptease explain.

4' Additional comments abo.rt tris person,s fiuress for the posrtion.

S'rgrranlre_ l e

Telephone ( )_

HARLAN INDEPENDENT SCHOOL DISTR.ICT420 EAST CENTRAL STREET - HARLAN, I(ENTUCKY M3T.2312

TELEPHONE (606) 573-8700

An Equal Educational and E^p6y^ent Opportunities Instittltoa

REC OMMENDATIOT{ FOR CERTIFICATED POSITIOF{

has $ven your name as a reference in support of

his/her apptication

this form and return

for the position of Grades-. Please cbmplete

it by to the Teacher Search Comminee at the address given above.

CANDI DATE APPRAISAL CH ECKLIST

^9*, on No. 7 (Eementary cardirates only): Are trere any ontent areas ln whi$ Ute candi@te b ercepthnalfy wenpreparod?f{oticeably weak? please erplain.

, l gtft8 / l< r / q

t 8-"-/

I E/EF/< /

i /o t

Please rate the candidate on each item below by ptacing an X in the appropriatebox. lf you do not have a basis for evaluating a particular statement, draw aline across f/re boxes. lf you would tike to comment on a particular rating,please use the space on the back under No. 4 or attach a separate slreet

1. Commr.rnicates effeAively in geaking and writing.

2. Works effeaively wih ofrer people.

3. ls deoend:ble.

4. AccepB resporsibillty br hMer actions.

5. Shotvs inithlive and leaderstrp irn canying out hMerduties

6. Exhibib r:rdeaEnding of ard empatry br studenrs.

7. ls kro,vledgeable in hMercontent area(s). -

8. Uses mefiods wiri'dr reflect loow{edge of ament educational researdr.

9. Demonstrates ability b phn effectivef for instuction.

10. Canies out lnstuction effecfively.

L$F a multisensory appmadt to teadring. induding hardsqr activiti,es where appopriate.

12 Manages chssroom time effectivety b acfiieir! a high lanl of llme on Esk br instrrtion.

13. Dernonstrates abi|rty b cmtd stldent betravbr ard tc employ eflectively pcitive medlods of disciptine.

14. Hardes required paperrrort h an efficient ard timely rnarner.

15. Oemonstrates a ssris d pofessirnal ethics ard persoral integify.

16. Demonsrates a will&qness b go beyond tre call of duty,

| 7. Dernonsfates an urderstandlng of arrd a @rnmit[n!nt t fie teaching pofessbn.

1. How long hare you knorrrn the !ndidate and in what posnion?

2' What clr you consider this p!rson's strengths as a te.ehea4n

q'.

3' Do you have any resenrations about this person's abilig or frtness for this job? lf so, ptease explain.

4' Additional comments abo.rt tris person,s fiuress for the posrtion.

S'rgrranlre_ l e

Telephone ( )_

HARLAN INDEPENDENT SCHOOL DISTR.ICT420 EAST CENTRAL STREET - HARLAN, I(ENTUCKY M3T.2312

TELEPHONE (606) 573-8700

An Equal Educational and E^p6y^ent Opportunities Instittltoa

REC OMMENDATIOT{ FOR CERTIFICATED POSITIOF{

has $ven your name as a reference in support of

his/her apptication

this form and return

for the position of Grades-. Please cbmplete

it by to the Teacher Search Comminee at the address given above.

CANDI DATE APPRAISAL CH ECKLIST

^9*, on No. 7 (Eementary cardirates only): Are trere any ontent areas ln whi$ Ute candi@te b ercepthnalfy wenpreparod?f{oticeably weak? please erplain.

, l gtft8 / l< r / q

t 8-"-/

I E/EF/< /

i /o t

Please rate the candidate on each item below by ptacing an X in the appropriatebox. lf you do not have a basis for evaluating a particular statement, draw aline across f/re boxes. lf you would tike to comment on a particular rating,please use the space on the back under No. 4 or attach a separate slreet

1. Commr.rnicates effeAively in geaking and writing.

2. Works effeaively wih ofrer people.

3. ls deoend:ble.

4. AccepB resporsibillty br hMer actions.

5. Shotvs inithlive and leaderstrp irn canying out hMerduties

6. Exhibib r:rdeaEnding of ard empatry br studenrs.

7. ls kro,vledgeable in hMercontent area(s). -

8. Uses mefiods wiri'dr reflect loow{edge of ament educational researdr.

9. Demonstrates ability b phn effectivef for instuction.

10. Canies out lnstuction effecfively.

L$F a multisensory appmadt to teadring. induding hardsqr activiti,es where appopriate.

12 Manages chssroom time effectivety b acfiieir! a high lanl of llme on Esk br instrrtion.

13. Dernonstrates abi|rty b cmtd stldent betravbr ard tc employ eflectively pcitive medlods of disciptine.

14. Hardes required paperrrort h an efficient ard timely rnarner.

15. Oemonstrates a ssris d pofessirnal ethics ard persoral integify.

16. Demonsrates a will&qness b go beyond tre call of duty,

| 7. Dernonsfates an urderstandlng of arrd a @rnmit[n!nt t fie teaching pofessbn.

1. How long hare you knorrrn the !ndidate and in what posnion?

2' What clr you consider this p!rson's strengths as a te.ehea4n

q'.

3' Do you have any resenrations about this person's abilig or frtness for this job? lf so, ptease explain.

4' Additional comments abo.rt tris person,s fiuress for the posrtion.

S'rgrranlre_ l e

Telephone ( )_