Academica West - Academica West - Director/Principal Application

Name:

School Applying For:

Present Address:
Street:
City: State: Zip Code:

Home Phone: (123) 456-7890

Mobile Phone: (123) 456-7890

Email Address:
Do you have legal authorization to work in the United States?
Please provide proper documentation.

Do you have an administrative license?
State(s):
Exp. Date:
License Level:
Are you under contract with a district?

Please list your endorsements:

What languages do you speak?
(indicate read/write/speak levels of low/med/high)

Please list extracurricular activities you are qualified to sponsor:

Education
(School or Institution, Address, Degree Received, Major, Minor, Date of Degree)

Administrative Internship
(School and District, Location, Dates, Grades, Responsibilities)

Contractual Administrative Experience
(School and District, City/State, Dates Mo/Yr to Mo/Yr, Grades/Subjects Taught, Reason for Leaving)

Other Work Experience
(Name of Employer, City/State, Job Title, Dates Employed Mo/Yr to Mo/Yr)

Professional References
(Name, Address, Phone, Relationship)

**Background Information:**
1.	Have you ever been convicted of, plead guilty, plead no contest to, or sentenced for any of the following:
	a.	a sex related crime which involved force or minors?
	b.	a crime involving violence, drugs or alcohol?
	c.	a felony?
	d.	Any offense other than a minor traffic violation?
2.	Have you ever:
	a.	had a professional certificate/license or other employment certificate/license revoked or suspended?
	b.	been under investigation for a revocation or suspension of a license?
	c.	had a hearing before a licensing board?
	d.	been involuntarily terminated from employment?
	e.	resigned a position to avoid dismissal?

Answering yes to any of these questions will not ...

***Please answer the following questions:***
Why do you want to be a Director/Principal? Describe your greatest success as an administrator: What do you feel are needed improvements in education? What special capabilities do you have that make you the administrator we should hire? How do your professional experiences align with the mission of the charter?

In accordance with Utah State Law, applicant consents that SCHOOL may conduct a criminal background check, and I hereby waive my rights to written notice of such.

No applicant for employment shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any educational program or activity on the basis of sex, race, religion, age, national origin or disability. Accommodations will be made as necessary for applicants with disabilities. If accommodations are necessary, please contact Crista Sanchez at Academica West at (801) 444-9378.

In connection with my application for employment with SCHOOL, I hereby authorize the SCHOOL to investigate my past and present work, education, and law enforcement records to ascertain any and all information which may be pertinent to my qualifications. I do hereby release all persons, firms, agencies, companies, groups or installations from any damages of, or resulting from, providing such information. I further agree that a copy of this release shall function as an original.

Date: (mm/dd/yyyy)

Signature: