RACINE UNIFIED SCHOOL DISTRICT

OFFICE OF STAFF PERSONNELSERVICES 2220 Northwestern Avenue Racine, Wisconsin, 53404 Application for Professional Position

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FOR OFFICE USE ONLY

Salary

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Schpol'Assignment

Starting Date

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(EQUAL OPPORTUNITY EMPLOYER)

it is the policy of the Racine Unified School Drstnct not lo Jiscnminale on ihe basis of sex in its educaiicital programs. d)(Jmissior>s policies arul pfannces. or emplovnent polices as fsnuireil by Title !X o( ihe 1972 Education Aniemlmenis

APPLICATION BLANK
Name in full Last Present Address Permanent Address General-Health Any defects in sight or hearing? Any other physical defects? Any mental or nervous problems requiring treatment? Are you a citizen of the United States of America'? By birth? II Pr^nt Positinr^ !/ ti*$**{> IMf tP ftraHa anrt Siihik/it'*.'**^I'' Grade and Su^tei
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.Social Security No First Middle Jelephoni Telephone, Estimate of occupational time lost due to illness during the last five years

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_By naturalization?. /A'$t.
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' Present Salary ^ ......tj$j

When can you accept a position?When does your present contract expire?, Position desired; Elementary Kindergarten to Grade 6, Inclusive What Grade? First Choice Second Choice /fr*^^ If elementary, can you teach music_ Are you certified to teach in the State of Wisconsin?

7Junior High School What Subject? Senior High School What Subject? Other

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..0*OI&fS$ -. phy,ed_ .in own classroom?

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Are you willing to come to Racine for an interview at your own expense?.

III. EDUCATIONAL PREPARATION PRIOR TO BEGINNING TEACHING

School Elementary High School College/ University College/ University College/ University Major Minor Name Dates Attended Location Specialization or Nature of Course Completed Degree or Diploma Date Graduated

ma.

Scholastic Honors Underline scholastic averages of undergraduate college work

IV. EDUCATIONAL TRAINING RECEIVED AFTER BEGINNING TEACHING

Institution Dates Attended Specialization or Nature of Course Followed Degree or Diploma Date Graduated

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Scholastic Honors, V. EDUCATIONAL EXPERIENCE (Do not include intern or practice teaching)
Years Name of School Address Specific Nature of Position No. Years Taught Annual Salary

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-19 -19

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Time

VI: 1 OTHER PROFESSIONAL EXPERIENCES (Educational Travel,'Leqturjng, Study, Publications;! Organizations:..)

Dates Nature of Experience

VII. ARMED SERVICE RECORD

Dates Branch of Service

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Total months in service Honorable discharge?.

VIM. ACTIVITIES Underline any of the following activities which you can direct successfully. Orchestra, Band, Chorus, Debate, Forensics, Dramatics, Football, Basketball, Baseball, Golf, Track, Volleyball, Tennis, Wrestling, Gymnastics, Swimming, SchoolJMewspapet. Annual, Others <-^^$g C.(yt>. *"" ~ List any college activities in which you engaged which may have prepared you to direct any of the above underlined activities O L l U ^O^&e, 4vg tfc t><*JUM J

IX. OTHER WORK EXPERIENCE (Business, trades, summer occupations, church work, social services, scouting, recreation, etc.l

X.

REFERENCES (Give the names of those who have closely observed your work as a teacher, employee, or as a student. Do not enclose letters of reference.)

XI. GENERAL (If you wish, give any additional information which you think might be of value in our considering you for a position in the Unified School District No. 1 of Racine County.)

Have yoCi ever-been convicted of a felony? Yes X. If yes, please explain by attached confidential letter.

No . Z J

I certify that all answers to 'questions m this application are true anc complete. I agree that any', nqisstatements or misrepresentation of facts is cause for rejection of'application or dismissal.
Photograph {Optional)

Date