Name:
First	MI	Last
Address:
Street Address	City	State	Zip Code
Telephone: Home:	Office:	Cell:
Current Position:	District:
Type of District:	K-8:	K-12:	Student Enrollment:
Annual Budget:	Number of Professional Staff:	Present Salary
Are you currently certified as a Superintendent in MO?	Yes:	(expiration date)	No:
(Please enclose copy of Mo Supt. Certificate if applicable)
OR Are you eligible to be certified as a Superintendent in Missouri?	Yes	No
Are you presently certified as a Superintendent in another state?	Yes	No
If yes, in what state(s)?

Educational Preparation - Beginning with Bachelor's Degree

DEGREE	YEAR EARNED	COLLEGE/UNIVERSITY	CITY/STATE

Educational Experiences to Date (include current assignment).

May a contact be made with your present employer? Yes No

FROM/TO	POSITION	INSTITUTION/LOCATION	ENROLLMENT

REFERENCES:

NAME	POSITION	ADDRESS	PHONE NUMBERS

BACKGROUND:

Have you ever been arrested for any violation other than minor traffic violations?	Yes	No
Have you ever been disciplined, discharged, or asked to resign from a prior position?	Yes	No
Have you ever resigned from a prior position after a complaint had been received against you or your conduct was under investigation or review?	Yes	No
Has your contract in a prior position ever been non-renewed?	Yes	No
Have you ever not been nominated for re-employment in a prior position or ever had your nomination for re-employment not be approved?	Yes	No
Have you ever been charged with or investigated for sexual abuse or harassment of another person?	Yes	No
Have you ever entered a plea of guilty or "no contest" (nolo contendere) to any crime (other than a minor traffic offense)?	Yes	No
Have you ever had a professional license or certificate suspended or revoked in any state, or have you ever voluntarily surrendered, temporarily or permanently, a professional license or certificate in any state?	Yes	No
Has any court ever deferred, filed or dismissed proceedings without a finding of guilty and required that you pay a fine, penalty or court costs and/or imposed a requirement as to your behavior or conduct or a period of time in connection with any crime (other than a minor traffic offense)?	Yes	No

If you have answered YES to any of the previous questions, provide full details on an additional sheet including, with respect to court actions, the date, offense in question, and the address of the court involved. Convictions or other disposition of a crime is not necessarily an automatic bar to employment. The Moniteau Co. R-V Board of Education reserves the right to conduct a criminal background check on any and all applicants.

APPLICATION PROCEDURE

Search being conducted by Missouri Association of Rural Education (MARE)

Applicants are advised to forward all application materials to Moniteau Co. R-V Superintendent Search, Dr. Paul Ricker, Search Consultant, 1899 Bittersweet Road , Lake Ozark, Missouri 65049

Applicants are asked not to make direct contact with the board of education members. Initial applications will be kept confidential; however, all applications, letters of reference, resumes, transcripts, credentials, etc., for the purpose of this application process will, upon receipt, become the sole property of the Moniteau Co. R-V Board of Education, and shall remain their property indefinitely.

Please include:

Completed application form and current resume with three letters of reference.

Cover letter directed to the Moniteau Co. R-V Board of Education. (Include reasons for interest in the position and a description of significant accomplishments over the past five years).

Evidence of Missouri Superintendent’s Certification or eligibility thereof, (copy of certificate).

Current transcript(s).

Any other supporting documents that would enhance the application file.

Forward credential file to: Moniteau Co. R-V Superintendency Search, Dr. Paul Ricker, Search Consultant,-1889 Bittersweet Road, Lake Ozark, Missouri 65049
STATEMENT OF NON-DISCRIMINATION Applicants for admission and employment, students and employees of the Moniteau Co. R-V School District are hereby notified that this institution does not discriminate on the basis of race, color, creed, religion, national origin, sex, age or handicap in admission or access to, or treatment of employment in its programs and activities. Any person implementing Title IX or Section 504 is directed to contact: Mrs. Tanya M. Brown, Superintendent of Schools, Moniteau R-V School District, 156 School Street, PO Box 367, Latham, Missouri 65050 Phone # (660) 458-6271 E-mail: tbrown@lathambraves.com

I understand that information submitted in and with this application may be disclosed to a screening and/or interviewing committee, which may include board members, administrators, other staff, and members of the community. I give my consent to this disclosure. I authorize investigation of all statements in this application and certify that all information included is complete and accurate.

Signature	Date