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Southwest Plains RSC CEO Search

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Southwest Plains RSC CEO Application

Please fill out the form below and click "Submit" to send your application.

Personal Data

Name:  (Last) (First) (M.I.)
E-mail Address (required):

Other name(s) under which transcripts, certificates, and former application may be listed:
                 (Last)(First)(M.I.)

 

 

 

 

Permanent Address

Number & Street:
City:
State:  Zip Code:

Phone Number:
Cell Number:  
Fax Number:  

Work Address

Number & Street:
City:
State:  Zip Code:

Phone Number:
Cell Number:  
Fax Number:  

Current Data

Current Employer:
Current Position:
Years in Position:

Most Recent Degree From:
Degree Earned:

Do you have 5 or more years teaching experience?  Yes  No

Do you have 5 or more years of school administrative experience? Yes  No

Do you have a masters degree (or higher) in education?  Yes  No

Do you have a current Kansas district-level license?  Yes  No

Administrative Experience
 
Employer and Position Title Location:
City, State
Dates:
From - To
(mm/yy)
Primary Supervisor

Significant Accomplishments in this position:
 

Reason for Leaving:
 

 

 
Employer and Position Title Location:
City, State
Dates:
From - To
(mm/yy)
Primary Supervisor

Significant Accomplishments in this position:
 

Reason for Leaving:
 

 

 

Teaching Experience

Employer and Position Title Location:
City, State
Dates:
From - To
(mm/yy)
Primary Supervisor

Significant Accomplishments in this position:
 

Reason for Leaving:
 

 

 
Employer and Position Title Location:
City, State
Dates:
From - To
(mm/yy)
Primary Supervisor

Significant Accomplishments in this position:
 

Reason for Leaving:
 


Education
Colleges, Universities and Technical Schools Attended:
Name and Location Major Degree Date Conferred

Please list honors, awards or distinctions.


Please list your professional memberships.  Please indicate leadership roles.
 

Please list your community and civic memberships and participation.
 

Please list any publications you may have, including your doctoral and/or master's dissertations, if appropriate.
 

Please list major presentations made to national, state or regional audiences.
 

Please list significant workshops or conferences which you would like to highlight.

Language Skills 
Please list any languages you speak other than English?

General Information

Please list any Certifications or Licenses you have.

Certificate/Licensure Type Issuing
State
Issue
Date
Expiration Date


List any additional information which will support your candidacy.

Are you presently under contract? Yes  No
If yes, when does your contract expire?  

Have you ever failed to have your contract renewed, be rehired, been asked to resign a position, 
or resigned to avoid termination? Yes   No
If yes, explain.
 

Have you ever had a credential or certificate revoked, suspended or annulled in any state, 
territory or foreign country?  Yes   No
If yes, explain.
 

Where did you hear of our vacancy?  

 

Legal Information
1.  Are you eligible to work in the United States?  Yes  No

2.  Have you ever been convicted of a felony or misdemeanor involving a sex offense 
    or a controlled substance?  Yes  No
    If yes, explain.  

3.  Have you ever had any indicated finding of child abuse filed in your name?  Yes  No
    If yes, explain.  

Confirmation
I authorize the organization(s) to which I am applying and Southwest Plains Regional Service Center to contact my references or any other references deemed necessary to ascertain the merits of my candidacy for this position.  I authorize references to discuss my application and/or release information concerning me, and agree to hold them, the District, and the consultants harmless for providing and/or utilizing any information requested and/or provide.

I also request that my application and interest in the administrative position remain as confidential as possible under the applicable laws of the state. I understand that my candidacy may become a matter of public record when I am presented to the Board.  I further understand that elements of my resume may be available to the public and the news media at such time.  However, I request that reasonable effort be taken to maintain the confidentiality of this application and other documents and information which accompany my application for the position of which I am applying. 

I hereby affirm that there are no misrepresentations, omissions or falsifications in the foregoing statements and answers, and that the entries made by me are true, complete and correct to the best of my knowledge and belief.  I acknowledge that any misrepresentations, omissions or falsifications might be grounds for dismissal if employed for this position.

Please initial the box below to signify your electronic signature.

 

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