The Monticello Central School District does not discriminate on the basis of age, color, 
creed, disability, marital status, veteran status, national origin, race, handicap, or sex 
in the educational programs and activities including co-vocational education opportunities 
which it operates. This policy is in compliance with Title IX of the Education Amendments 
of 1972 and Section 504 Rehabilitation Act of 1973. 

Inquiries concerning this policy may be referred to the District's Title IX Coordinator and 
Section 504 Coordinator, Ms. Kathleen Pagano-Fuller, Assistant Superintendent, 237 Forestburgh Road, 
Monticello, NY 12701.

Name (please print or type) _________________________________________________

Date __________________________________________________________________

Position desired __________________________________________________________

To begin (mo. yr.) _________________________________________________________

Other choice: ____________________________________________________________

Home Address ___________________________________________________________

Home Phone _____________________________________________________________

Present Address __________________________________________________________

Present Phone/School Phone _________________________________________________

New York State Teacher's Retirement Number ___________________________________

Social Security Number _____________________________________________________

Certification Status

1. _____________________________________________________________________

2. _____________________________________________________________________

3. _____________________________________________________________________

If not certified in New York State, have you applied for New York State 
Certification? Please explain. _______________________________________________

Professional Preparation

1. ______________________________________________________________________

2. ______________________________________________________________________

3. ______________________________________________________________________

Record of Experience

1. _______________________________________________________________________

2. _______________________________________________________________________

3. _______________________________________________________________________

References
Include Superintendent, Principal, Supervisor, Critic, Teacher, or others directly 
responsible for evaluating your work. 

1. _______________________________________________________________________

2. _______________________________________________________________________

3. _______________________________________________________________________

Please ask your placement office to forward your confidential placement papers 
and your college registrar to forward your transcripts to this office. 

Academic Average:   Undergraduate _______________   Graduate _________________

Where did you do your student teaching? _______________________________________

When? ________________________________________________________________

Mark recieved for student teaching ___________________________________________

Have you received tenure in any other district?   Yes    No

Name of district __________________________________________________________

Date of tenure ___________________________________________________________

Please describe briefly the personal and professional strengths you would bring to 
the district. (Please attach a separate sheet)

Have you ever been convicted of a crime?   Yes    No    
If so, please explain in a confidential letter. This information given by the 
application will be verified through law enforcement agencies. 

Agreement

I hereby certify that the above information to the best of my knowledge is true, 
accurate, and complete.  Any misrepresentation or willful omissions of facts 
shall be sufficient cause for disqualification of this application or termination 
of employment.  Furthermore, it is understood that this application and records 
become the property of the District which reserves the right to accept or reject 
it.  I further agree to observe all rules, regulations, and policies of the District. 

_________________________________________________
Signature of applicant

I hereby authorize the District to conduct work history, personal reference, or 
police record inquiries to determine my acceptability for employment. 

_______________________________________________________________________
Date and Signature of applicant