Leland School District 408 East Fourth Street Leland, MS 38756
Application for Employment – Certified Staff
personal	last name	first name	middle	date
Street Address	home telephone [ ]
city, state, zip	business telephone [ ]
e-mail address	cell telephone [ ]
position desired	social security # __ __ __ - __ __ - __ __ __ __
date of birth
education	school	name/location of school	major	no. of years	did you	Degree or
completed	graduate?	Diploma
elementary
high school
college
graduate
certification
*Mississippi Certification:	Type License	A□	AA□	AAA□	AAAA□
Area of Certification:	PLEASE ATTACH COPY OF CERTIFICATE
character determination
___	Yes	___	No	Are you currently addicted or currently dependent on alcohol?
___	Yes	___	No	Are you currently addicted or currently dependent on other habit forming drugs?
___	Yes	___	No	Are you a habitual user of narcotics, barbiturates, amphetamines, hallucinogens, or other drugs having similar effects?
___	Yes	___	No	Have you been convicted, pled guilty, or entered a plea of nolo contendere to a felony as defined by federal or state law?*
___	Yes	___	No	Have you been convicted, pled guilty, or entered a plea of nolo contendere to a sex offense as defined by federal or state law?*
___	Yes	___	No	Have you had a teaching certificate/license denied, suspended, and/or revoked by another state?
* If yes, submit official copies of court record including disposition of case.
please attach a resume to application

employment	Please give an accurate and complete employment record. Start with your present or most recent employer.
1	school district/company name	telephone [ ]
address	Employed (month and year) from to
name of supervising administrator	salary
job title	reason for leaving
2	school district/company name	telephone [ ]
address	Employed (month and year) from to
name of supervising administrator	salary
job title	reason for leaving
3	school district/company name	telephone [ ]
address	Employed (month and year) from to
name of supervising administrator	salary
job title	reason for leaving
4	school district/company name	telephone [ ]
address□	Employed (month and year) from to
name of supervising administrator	salary
job title	reason for leaving
The above employers may be contacted.	do not contact:
Indicate those you do not want to contact.	employer number(s)_____ reason:
military	did you serve in the u.s. armed forces? □ yes □ no	if “yes,” in what branch?
signature	the information provided in this application is correct and complete
date	signature
prospective employees will receive consideration without discrimination because of race, creed, color, sex, age, national origin, or handicapping condition.

Revised: 11.12.2021

Please return your application, resume, and credentials (if any) to the above address or email jesseking@lelandk12.org. Thank you for considering the Leland School District.