Parishville-Hopkinton Central School Application for
Superintendent of Schools
Parishville-Hopkinton Central School District
 

Please forward copies of the following materials by the deadline of Friday, March 24, 2017:

Mail or email information to:

Mr. Thomas R. Burns, District Superintendent
St. Lawrence-Lewis BOCES
P.O. Box 231 – 40 W. Main Street
Canton, New York  13617
Email:  Maureen Bouchey, Secretary to the District Superintendent – mbouchey@sllboces.org

Please direct all questions related to the superintendent search to Mr. Thomas Burns, District Superintendent.  We ask that you do not contact the board members.

Applicant Information

Last Name First Middle Initial
Street Address Apartment/Unit #
City State ZIP
Phone Home Phone Cell Phone Work
Email Current Salary Current Position # of Years in Position
NYS Retirement Membership # % of Pension Contribution District Enrollment
School District Budget Amount # of Personnel Responsible To You:  Instructional # of Personnel Responsible To You:  Non-Instructional
Are you a citizen of the United States? YES NO  If no, are you authorized to work in the U.S.? YES NO
Have you ever been convicted of a crime (misdemeanor and/or felony)? YES NO If so, when?
Are any criminal charges or proceedings pending against you? YES NO If yes, explain
Have you ever been dismissed from a position or resigned to avoid dismissal? YES NO If yes, explain
Have you ever resigned from a position to avoid the effects of a denial of tenure? YES NO If yes, explain
Have you ever resigned as an alternative to facing any type of charges or dismissal? YES NO If yes, explain
Have you ever been the subject of Part 83 notification to the NYS Education Dept.? YES NO If yes, explain
Have you ever had a teaching/administrative certificate revoked, suspended, surrendered, or annulled? YES NO If yes, explain
Are you legally eligible for employment in this country? YES NO If employed, you will be asked to produce two original forms of identification.

Education

High School
From To Did you graduate? YES  NO  Degree
College Major/Minor
From To Did you graduate? YES  NO  Degree
College Major/Minor
From To Did you graduate YES  NO  Degree
Other Major/Minor
From To Did you graduate? YES NO  Degree
Internship - School Name Grade Level
Areas of Responsibilities

Military

Branch of Service Rank Specialty
Dates of Service Type of Discharge

CERTIFICATION

Certification Title Expiration Date
Date Issued State
Certification Title Expiration Date
Date Issued State
Certification Title Expiration Date
Date Issued State
Certification Title Expiration Date
Date Issued State

TENURE STATUS

Were you ever appointed tenure in a public school district in New York State? YES  NO  Tenure Area
Name and address of school district where tenure was granted.
Were you ever appointed tenure in a public school district in New York State? YES  NO  Tenure Area
Name and address of school district where tenure was granted.
Were you ever appointed tenure in a public school district in New York State? YES  NO  Tenure Area
Name and address of school district where tenure was granted.

Employment

Company Phone
Address Supervisor
Job Title Starting Salary Ending Salary
Responsibilities
From To Reason for Leaving
May we contact your previous supervisor for a reference? YES  NO 
Company Phone
Address Supervisor
Job Title Starting Salary Ending Salary
Responsibilities
From To Reason for Leaving
May we contact your previous supervisor for a reference? YES  NO   
Company Phone
Address Supervisor
Job Title Starting Salary Ending Salary
Responsibilities
From To Reason for Leaving
May we contact your previous supervisor for a reference? YES  NO 

References

Please list three professional references.
Full Name Relationship
Company Phone
Address
Full Name Relationship
Company Phone
Address
Full Name Relationship
Company Phone
Address

PROFESSIONAL MEMBERSHIPS

Please list your professional memberships:

DISCLAIMER AND SIGNATURE

I hereby certify that the above information, together with any additional information furnished in conjunction with this application, is furnished for the purpose of gaining employment, and is true to the best of my knowledge and belief.  I understand that such information shall be the basis of me being considered for employment, and that false statements may result in my application not being considered or my dismissal from future employment. Authorization is hereby given to Parishville-Hopkinton Central School District and the District Superintendent to obtain reference checks from any of the named sources in this application and the sources to release information if requested by Parishville-Hopkinton Central School District or the District Superintendent. I understand that the District Superintendent and/or school district will be making an extensive inquiry regarding my background and experience and I hereby release from any liability anyone giving information regarding me, whether specified in my application or not, so long as the information given is relevant to the duties for which I have applied.  I understand that the information gathered, in part or whole, may be shared with members of the school district involved in the search process.  I further understand that all information gathered by you regarding my application will be the property of the school district and will not be released to me unless required by federal or state statues or regulations. The Parishville-Hopkinton Central School District, in compliance with Title IX of the Education Amendments of 1972 and Regulation 504 of the Rehabilitation Act 1973, does not discriminate on the basis of race, creed, color, gender, age, national origin, disability, gender identity or expression, genetic information or testing, veteran status, sexual orientation, or other protected class per law.
Signature Date
I have requested my placement file be forwarded from (Institution):

Willful misrepresentation of an actual fact may result in dismissal of an applicant hired or retained by the school district.
We are in compliance with the Educational Amendments of 1972; Title IX, specifically disallowing any practice of discrimination.