LICKING COUNTY
EDUCATIONAL SERVICE CENTER
675 Price Rd., Phone: 740-349-6084
Newark, Ohio 43055
2007-2008 APPLICATION FOR SUBSTITUTE TEACHING
Name: ______Maiden:______Birthdate:______
Address: ______
(City) (State) (Zip)
Phone: ______Soc. Sec. No.: ______
PLEASE CHECK THE DISTRICTS IN WHICH YOU WOULD BE WILLING TO SUBSTITUTE:
Johnstown-Monroe Licking Heights North Fork Southwest Licking
Lakewood Licking Valley Northridge Licking Co. ESC**
**PLEASE CHECK THE LICKING COUNTY ESC CLASSES YOU WOULD BE WILLING TO SUBSTITUTE IN:
(Multiple Disabilities (MD), Emotional Disturbance (ED) & Preschool classes)
□ Granville Elm (MD) / □ Utica Elm (MD) / □ Licking Heights H.S. (ED)□ Granville H.S. (MD) / □ Utica H.S. (MD) / □ Alexandria Elm (ED)
□ Garfield Elm (MD) / □ Stevenson Elm (MD) / □ The Citadel (ED)
□ Madison/Licking Valley Elm (MD) / □ Northridge M.S./H.S. (MD) / □ Preschool – 119 Union St. Newark
□ Kirkersville Elm (MD) / □ The Citadel (MD) / □ Preschool – C-TEC
□ Licking Valley M.S. (MD) / □ Heath M.S. (MD) / □ Preschool – Licking Heights West
□ Licking Valley H.S. (MD) / □ Licking Heights Central (ED) / □ Preschool – Jackson Elementary
PLEASE NOTE: ED/MD Class Locations are Subject to Change
REQUIREMENTS FOR NEW SUBSTITUTE TEACHERS and CURRENT SUBSTITUTE TEACHERS:
1. Copy of current OHIO Certificate (contact our office for an application if you have not yet applied)
2. Fingerprint Results within the last year (applies if you did not sub for us during the 2006-07 school year – note that ODE requires a new electronic background check each time you renew your license)
3. Copy of TB Test results within the last 90 days (applies if you did not sub for us during the 2006-07 school year)
4. Copy of a Sub Training Class Certificate (for new substitutes without teaching experience)
OHIO CERTIFICATE EXPIRES (Year) ______APPLYING FOR CURRENT CERTIFICATE
Have you substituted for us before? No Yes When? (year/s) ______
Have you had previous teaching/sub experience? No Yes
Where ______Contact Name ______Phone Number ______
Reminder: If you haven’t had previous teaching experience in a formal classroom setting, you must attend a substitute training class and provide us with a certificate of completion. Education majors who have student teaching experience need not take the class. Please note field experience is not teaching experience.
(Please complete next page)
Page 2 – Substitute Form
Have you lived in only the state of Ohio for the past 5 consecutive years?
Yes _____ No _____
Have you ever been convicted of any of the following: a) a misdemeanor that would be a felony on the second offense; b) any sex offense; c) any offense of violence; d) any theft offense; e) any drug abuse offense?
Yes _____ No _____
If yes, please explain nature and date(s) of occurrence(s):
______
______
______
______
Have you ever been Non-renewed? ____ Suspended? ____ Terminated? ____ Rif’ed? ____
Are you currently retired and receiving STRS Benefits? ______
REFERENCES: List the name and address of two educators who would be familiar with your teaching ability. If you have no teaching experience, please list the name and address of two people who can verify your past employment history.
______
______
It is understood and agreed that the Licking County Educational Service Center may contact former employer(s) for verification of any employment history and the Bureau of Criminal Identification and Investigation (BCII) for a background check and I hereby consent to such inquiries.
I further understand that falsification of any and all information on this application shall result in my being disqualified from employment or in my employment being terminated. By affixing my signature, I agree to the conditions listed on this application and will, if employed, tender my resignation of employment should I fail to fulfill these conditions.
SIGNATURE ______DATE ______
An Equal Opportunity Employer
NOTE: A new application must be filed with this office each year you wish to be placed on the substitute list.