FOR OFFICE USE ONLY:

DATE ISSUED

LEVEL OR SUBJECT

FOR OFFICE USE ONLY: Date: New York State Law Prohibits

Sent for Received Discrimination Because of Race,

Letter of Application Color, Creed, Nationality, Sex, Age

References Disability or Marital Status

No Opening Letter

Position Filled Letter

SCHOOL BUSINESS ADMINISTRATOR

APPLICATION FOR POSITION IN

RAVENA-COEYMANS-SELKIRK CENTRAL SCHOOL

26 Thatcher Street, Selkirk, NY 12158

(518)756-5201

Fax: (518)767-2644

Date Name Social Security No.

Present Address Tel. No.

Permanent Address Tel. No.

(if different from above)

NYS Teacher’s Retirement No. (if applicable)

Present Position

Do you have a legal right to work in the United States? Yes No

If not, why?

Have you been fingerprinted before? Yes No

Are you able to perform the duties of a supervisor, with or without reasonable accommodations?

Yes No

Other Subjects

List below all certificates which you now hold, including any out of state.

List the types of any certificates for which you are working and the date you expect to receive them.

Have you received prior tenure? Yes No

Where When

Area

IN UP STATE NEW YORK’S CAPITAL DISTRICT

EDUCATIONAL AND/OR PROFESSIONAL TRAINING

Wherever space is insufficient, use last page

Name School or Institution, City & State	Major	Degree or Diploma	Date	Time Spent	Number of Credits
College(s)


Graduate Work

RECORD OF WORK EXPERIENCE

Please list in strict chronological order all work experience including present position, student and regular teaching, acquired since graduation from high school including military service.

Dates		Name & Address of Employer and/or School District and School Bldg.	Business or Grade or HS Subjects	Salary	Reason for Leaving
From	To

Number of days absent past three years

Enumerate other experiences which may be related to your field or from which you feel you gained something of value.

Professional contributions (list any articles, books, etc., that you have had published.

Current Interests:

List any awards or honors you received while in high school, college or on the job.

List any professional organizations of which you are a member:

REFERENCES: Give at least three references, including those who have firsthand knowledge of your character, personality, scholarship and ability; cover letter; resume; placement file; copy of transcript, and certification to:

Greg Chase

Director of Human Resources

26 Thatcher Street

Selkirk, NY 12158

Please write in your own handwriting a brief statement about what you feel to be the most important function of a supervisor at your level. This statement may be included on this application, or you may write a separate statement and attach it to the application.

Applicant’s Signature Date