P. O. Box 23120
3820 Nine Mile Road
Henrico, Virginia 23223-0420
I have applied for a position in the Henrico County Public School System and would appreciate any information you
may offer in regard to the items below. Please complete this form and return to the Department of Human
Resources at the above address. I understand that this information will not be provided to me. Thank you for your
response to this request.
Name of Applicant (First, Middle Initial, Last) Date
Signature of Applicant Position Applied for
All applicants may be evaluated on the checklist below. Page two of this document may be used for those applicants who have not
taught and as an elaboration of the checklist. Clerical and paraprofessional personnel may also be evaluated on page two. Thank you
for your cooperation.
Please check ( √) each of the items below.
Model for Students
Evaluation of Student Progress
Rapport with Students
Preparation and Organization of Learning Activities
Is person under contract? yes
□ no □ Would you reemploy? yes □ no □
Indicate exact Grades or subjects taught _______
dates of service