Falls Lake Academy
1701 East Lyon Station Road, Creedmoor, NC 27522
A place where community and education combine to celebrate each child's ambitions so
that their full potential can TAKE FLIGHT!
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Application for Employment: Professional / Certified
Teacher, Administrator, Student Services Specialist
Personal Information |
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Date of Birth Social Security # |
All employment is subject to satisfactory criminal background check. |
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Current Certifcation
Type of Certificate and Certificate Area
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PRAXIS Scores (or other state certifying scores - indicate which tests): |
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Employment History Please list all employment within the last five years in reverse chronological order beginning with current or most recent employment. If your last teaching or other school-based employment ended more than five years past, start with that one and then indicate all other employment in reverse chronological order as instructed. |
Position (ex: 3rd grade Teacher, etc.) |
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Employing Institution / Organization |
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Supervisor: Name, Phone, E-mail |
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Position (ex: 3rd grade Teacher, etc.) |
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Employing Institution / Organization |
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Supervisor: Name, Phone, E-mail |
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Position (ex: 3rd grade Teacher, etc.) |
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Employing Institution / Organization |
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Supervisor: Name, Phone, E-mail |
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Position (ex: 3rd grade Teacher, etc.) |
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Employing Institution / Organization |
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Supervisor: Name, Phone, E-mail |
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Position (ex: 3rd grade Teacher, etc.) |
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Employing Institution / Organization |
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Supervisor: Name, Phone, E-mail |
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Co- and Extra-Curricular Activities Please list any sports, clubs, or student activities for which you are |
qualified and interested in directing, coaching, or advising: |
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The NC Department of Public Instruction requires all applicants to answer the following questions. IF YOU ANSWER "YES" TO ANY QUESTION, ATTACH A DETAILED WRITTEN EXPLANATION. IF YOU ANSWER "YES" TO ANY QUESTION RELATING TO A COURT PROCEEDING, A CERTIFIED TRUE COPY OF THE COURT RECORD MUST ACCOMPANY THIS APPLICATION.
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Criminal
1. Are you on a child abuse registry or a sex offender registry of any kind. |
2. Have you ever been, or are you currently being, investigated for alleged or suspected child abuse or neglect by any governmental agency? (If yes, provide explanation and documentation.) |
3. Have you ever been convicted, pled guilty, or pled nolo contendere (no contest) to any criminal offense other than a minor traffic violation (examples of criminal offenses would include, but are not limited to, the following: felony, misdemeanor, Driving While Impaired)? Please include any conviction, regardless of pardon. You must explain relevant circumstances in detail. NOTE: In response to this question, include all offenses other than minor traffic offenses. The following are not minor traffic offenses and must be listed: DWI, DUI, Failure to Stop in the Event of An Accident (hit and run), and Driving While License Revoked or Suspended (DWLR). (If yes, provide explanation and documentation.) |
4. Have you ever recieved probation, deferred prosecution, or any type of pre-trial adjudication, including a PJC(prayer for judgment) other than for a minor traffic offense? [Note: This question does not seek information about matters for which the records have been expunged by a court order.] (If yes, provide explanation and documentation.) |
5. Have you ever participated in a diversion program in lieu of prosecution? [Note: This question does not seek information about matters for which the records have been expunged by a court order.] (If yes, provide explanation and documentation.) |
6. Have you ever been arrested, indicted, or otherwise charged with a crime other than for a minor traffic offense regardless of whether you were convicted or whether the charges were dropped? [Note: This question does not seek information about matters for which the records have been expunged by a court order.] (If yes, provide explanation and documentation.) |
7. Are you currently named in a pending criminal charge, indictment or special presentment of any offense other than for a minor traffic violation? [Special Presentment is used in some jurisdictions to charge an individual with a crime.] If yes, provide explanation and documentation.) |
Professional Licensing
8. Have you ever had a professional certificate, credential, or license of any kind revoked or suspended, or one surrendered prior to its expiration? (If yes, provide explanation and documentation.) |
9. Have you ever been reprimanded, censured, placed on probationary status, or suspended by a licensing board, commission or agency for any alleged misconduct or alleged violation of professional standards of conduct? (If yes, provide explanation and documentation.) |
10. Are there any pending adverse actions or investigations against you relating to a professional certificate, credential, or license in NC, any other state or country? (If yes, provide explanation and documentation.) |
11. Have you ever been denied a professional license for which you applied? (If yes, provide explanation and documentation.) |
12. Have you ever been granted a professional license on a conditional or probationary basis for any alleged misconduct or alleged violation of professional standards of conduct? (If yes, provide explanation and documentation.) |
13. Have you ever been disciplined by any board, commission or agency responsible for licensure of any kind including, but not limted to, educational licensure? (If yes, provide explanation and documentation.) |
Employment [See note below]
14. Have you ever been dismissed from employment by a school or school system for any reason, or been dismissed or had a contract non-renewed or non-extended by any employer for reasons of misconduct as defined in this application? [Non-extended means a contract or term of employment was not renewed.] (If yes, provide explanation and documentation.)
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15. Have you ever had a disciplinary suspension, or resigned, or been non-renewed or dismissed following allegations of behavior for misconduct related to your employment or arising out of your employment? [Note: This question does not seek information about any suspension with pay or administrative leave for which the records have been removed from your Central Office personnel file.] (If yes, Provide explanation and documentation.) |
16. Have you ever been, or are you currently being, investigated or charged by a licensing board, commission or agency with a violation of a Professional Code of Ethics or any similar code of conduct? (If yes, provide explanation and documentation.) |
NOTE: For purposes of this application, "misconduct" means the following:
(1). conviction of a crime other than a minor traffic offense;
(2). use of excessive or inappropriate force against a minor that causes an observable physical injury;
(3). inappropriate interaction with a student of a sexual or romantic nature;
(4). theft, embezzlement or fraud related to school funds or property;
(5). illegal use of weapons or firearms on school property or at school-sponsored events;
(6). use of drugs or alcohol involving students;
(7). violation of the State Testing Code of Ethics; or
(8). excessive use of alcohol or nonmedical use of a controlled substance as defined in Article 5 of Chapter 90 of the General Statutes, provided that there is a reasonable and adverse relationship between the underlying conduct and the continuing ability of the person to perform any of his/her professional functions in an effective manner. |
References Please list three references below. Your current supervisor, or most recent supervisor if not currently employed, must be one of the three listed below. Current students may list their primary advisors as their current supervisors. You may also submit letters of reference from these and/or others, but if you are considered for employment, these three referencing individuals will be contacted. |
Institution, Organization,
or Business - Name, Location
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Attestations and Signature Please initial the spaces to the left of each of the statements below, indicating that you have met the specified conditions of employment. Note that false information or statements on this application can result in disqualification for employment consideration or immediate dismissal once employed. |
I am legally eligible for employment in the United States. |
I understand that, in the event an offer of employment is made and a contract is signed, my employment is subject to satisfactory results of a criminal background check, which is mandatory for all FLA employees. |
I have read and I understand all the information contained in the document "Teaching at FLA" (available for download under the "Employment" tab at http://fallslakeacademy.com). I agree that, if employed, I will consider myself bound by these tenets and will support and adhere to the FLA mission and objectives to the best of my ability. |
All information provided on this application and in all attached documentation is complete and accurate to the best of my knowledge |
My signature below authorizes Falls Lake Academy to conduct a background investigation and authorizes release of information in connection with my application for employment. This investigation may include information as to criminal or civil convictions, driving records, previous employers, educational institutions, personal references, professional references, and other appropriate sources. I waive my right of access to any such information, and without limitation hereby release Falls Lake Academy and the reference source from any liability in connection with its release or use. This release includes the sources cited above and specific examples as follows: local and state Sheriff and police departments, information from the North Carolina and/or other State Departments of Social Services and/or Child Protective Services Units and any Locality to which they may refer for release of information pertaining to any findings of child abuse or neglect investigations involving me. Furthermore, I certify that I have made true, correct, and complete answers and statements on this application in the knowledge that they may be relied on in considering my application. I understand that any omission(s) or falsely answered statements(s) made by me on this application, or any supplement to it, will be sufficient grounds for failure to employ or for my discharge should I become employed with Falls Lake Academy. |
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Falls Lake Academy does not discriminate on the basis of race, color, national origin, age, religion, political affiliation, handicapping conditions, or sex in its hiring or employment practices. No person shall be denied employment solely because of any impairment which is unrelated to the ability to engage in activities involved in the position for which application has been made. |
Include with application: |
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