MAINE SCHOOL ADMINISTRATIVE DISTRICT #37

Addison, Cherryfield, Columbia, Columbia Falls, Harrington, Milbridge

ADMINISTRATOR APPLICATION

Personal Information

Name: _______________________________________________________________________________

Address: _____________________________________________________________________________

Home phone: ___________________________ Work phone: ______________________________

Social Security Number: _________________________________________________________________

Position you are applying for: _________________________________________________________________

I. CURRENT INFORMATION:

A. Are you presently under contract in a school system? Yes ______ No ______

B. Are you retired from the Maine State Retirement System? Yes ______ No ______

C. If so, when does your contract expire: ___________________________________________________

D. Name of system: ____________________________________________________________________

E. Position: _____________________________ Present Salary: ___________________________

II. CERTIFICATION INFORMATION:

A. Are you currently certified as an Administrator in Maine?

Yes____

No___

B. Are you eligible to be certified as an Administrator in Maine?

Yes____

No___

C. Are you presently certified as an Administrator in another state?

Yes____

No___

If yes, what State(s)? _________________________________________________________________

NOTE: Candidates who do not hold Maine certification should contact the Maine Department of Education, Division of Certification, 23 State House Station, Augusta, Maine 04333-0023, or call (207) 287-5944.

III. ACADEMIC/PROFESSIONAL TRAINING:

College/University Attended

Location

Degree

No. Years Completed

_______________________________________________________________________________________

Please have copies of your college/university transcripts sent to the Superintendent’s Office if not enclosed in your application packet.

IV. MEMBERSHIPS IN PROFESSIONAL ORGANIZATIONS:

_______________________________________________________________________________________

V. PROFESSIONAL EXPERIENCE:

Position/Responsibilities School System No. of Years From/To

______________________________________________________________________________________

_______________________________________________________________________________________

OTHER RELEVANT WORK EXPERIENCE/ACHIEVEMENTS:

_______________________________________________________________________________________

The Board of Directors of MSAD #37 is committed to conducting a thorough screening of applicants for all positions and requires the completion of the following questions of all candidates:

Have you ever been disciplined, discharged, or asked to resign from a prior position?

Yes___

No___

Have you ever resigned from a prior position after a complaint had been received

against you or your conduct was under investigation or review?

Yes___

No___

Has your contract in a prior position ever been non-renewed?

Yes___

No___

Have you ever not been nominated for re-employment in a prior position or ever

had your nomination for re-employment not be approved?

Yes___

No___

Have you ever been charged with or investigated for sexual abuse or harassment

of another person?

Yes___

No___

Have you ever been convicted of a crime (other than a minor traffic offense)?

Yes___

No___

Have you ever entered a plea of guilty or “no contest” (nolo contendere) to any

crime (other than a minor traffic offense)?

Yes___

No___

Have you ever had a professional license or certification suspended or revoked in

any state, or have you ever voluntarily surrendered, temporarily or permanently,

a professional license or certificate in any state?

Yes___

No___

Has any court ever deferred, filed or dismissed proceedings without a finding of

guilty and required that you pay a fine, penalty, or court costs and/or imposed a

requirement as to your behavior or conduct for a period of time in connection with

any crime (other than a minor traffic offense)?

Yes___

No___

If you have answered YES to any of the previous questions, provide full details on an additional sheet including, with respect to court actions, the date, offense in question, and the address of the court involved. Conviction or other disposition of a crime is not necessarily an automatic bar to employment.

My signature below constitutes authorization to check my employment history, including without limitations, criminal arrest and conviction record checks, reference checks, and release of investigatory information possessed by any state, local, or federal agency. I further authorize those persons, agencies, or entities that MSAD #37 contacts in connection with my employment application to fully provide MSAD #37 any information on the matters set forth above. I expressly waive in connection with any request for or provision of such information, any claims, including without limitation, defamation, emotional distress, invasion of privacy, or interference with contractual relations that I might otherwise have against MSAD #37, its agents and officials, or against any provider of such information.

I understand that information submitted in and with this application may be disclosed to a screening and/or interview committee, which may include board members, administrators, other staff, and members of the community. I give my consent to this disclosure.

Confidentiality of application information will be maintained in accordance with Maine statutes. No information will be released to the public without prior notice being made to the candidate.

___________________________________

APPLICANT SIGNATURE/DATE

APPLICATION FOR ADMINISTRATIVE POSITION CHECK LIST: The completed employment application cannot be evaluated unless all of the following materials have been provided:

1. Complete and sign this application form.

2. Enclose three letters of reference including at least one

from your last employer.

3. Include a current resume.

4. Submit college/university transcripts.

5. Include a copy of your current certification.

6. Send all information to: Superintendent’s Office

P.O. Box 79, Harrington, Maine 04643

Revised: March, 2002