Career & Technical Education Teacher Preparation Program (CTETPP)

2015-2016 Program Application

BROOKDALE COMMUNITY COLLEGE

765 Newman Springs Road, Lincroft, NJ 07738-1597

PLEASE CHECK ONE: ¨Non-Credit ¨Credit

Please complete the following:

Social Security #: / / Sex: o Male o Female Date of Birth: / /

Name:

Last First Middle Initial Maiden

Address:

Street City State Zip Code County

Phone: (H) (C) Email:

Admission Requirements: Must have a CTE Certificate of Eligibility and proof of employment.

All applicants must include a copy of their employment contract or a letter from their district indicating proof of employment as a provisional teacher. The contract or letter must include the subject area the applicant has been hired to teach.

List all Certificates of Eligibility (CE):

Subject: CE #:

Subject: CE #:

Any additional CEs you may be applying for:

School Information:

School employed by: Subject taught: __

School Address:

Street City State Zip Code

Principal Information:

Principal’s Name: Principal’s Phone:

Principal’s Email:

Please mark the box to indicate race/ethnic group which best applies to you (optional). Responses to the following questions are solely voluntary. Refusal to provide this information will not subject the applicant to any adverse treatment.

Ethnicity (check one): ¨Hispanic/Latino ¨Non-Hispanic/Latino

Race (check one or more): oAmerican Indian/Alaskan Native oAsian oBlack/African American

oNative Hawaiian/Other Pacific Islander oWhite

Brookdale Community College is an Equal Opportunity/Affirmative Action educational institution. In order to promote this goal, the College makes positive efforts to ensure equal opportunity to all individuals without regard to race, color, sex, religion, national origin, disability or veteran status.

The statements made in this application are accurate and complete to the best of my knowledge. Failure to provide full documentation or falsification of credentials may result in cancellation of admission to this program.

I have not been convicted of a criminal offense, nor do I have any criminal charges pending.

Signature Date

***IMPORTANT - PLEASE COMPLETE ADDITIONAL INFORMATION ON PAGE 2***


Career & Technical Education Teacher Preparation Program (CTETPP)

2015-2016 Program Application – Part 2

Education:

High school last attended City & State

Highest grade completed Year of graduation

Do you have an equivalency diploma (GED)? ¨Yes ¨No

If yes, from what state?

List all schools/colleges/universities attended after high school:

School / City & State / Month & Year / Degree/Subject Area
/ to /
/ to /
/ to /
/ to /

If you attended college but did not receive a degree, please indicate the total number of credits you received:

If you do not have a degree, are you considering continuing your education?

o In the next five years

o Some other timeline

o No

If you are entering the CTE Alternate Route Program using experience only, please indicate your past career and number of years in that field:

Past Career: Number of Years:

Submit Completed Application and Supporting Materials to the CTE Alternate Route Office:

By Mail: By Fax: As Email Attachments:

Kelly Canonico, CTE Project Coordinator 732-224-2664

Brookdale Community College ATTN: Kelly Canonico

Continuing & Professional Studies

765 Newman Springs Road

Lincroft, NJ 07738-1597

CTE Program Application Page 2 of 2