Certificated Position for Which You Are Applying Date

GARVEY SCHOOL DISTRICT

CERTIFICATED EMPLOYMENT APPLICATION

Certificated Position for Which You Are Applying Date

P L E A S E P R I N T C L E A R L Y O R T Y P E

1. NAME 2.

First Last Initial Social Security Number

List other name(s) used in employment

3. ADDRESS A) ( )

No. & Street Apt. No. (Area Code) Home Phone Number

B) ( ) City State (Area Code) Contact Phone Number

Email address: C) ( )

(Area Code) Cellular/Pager Number

4. Total number of years teaching:

5. Date you would be available for work:

Applicants, if employed, will be required to be fingerprinted for a criminal records check and required to submit proof of their legal right to work in the U.S.

The law provides equal employment opportunity regardless of race, religion, sex, age, physical handicap or national origin. Employment acceptance or rejection will be based on job related criteria.

The following information must be included with your application in order for the application to be considered complete:

·  Resume or Vita, or recent references from your immediate supervisors

·  Copies of appropriate Credentials

·  College Transcripts

·  CBEST Test Results

The legibility, completeness and grammatical correctness of the application will be included in the candidate’s qualifications for the position.

NOTE: THE COMPLETENESS AND RECEIPT OF ALL MATERIALS ARE THE CANDIDATE’S RESPONSIBILITY.

6. CALIFORNIA CREDENTIAL INFORMATION (include out-of-state credentials)

Credential(s) now held / Authorized Subject Areas / Expiration date(s)

(Attach copies of above listed credentials.)

If no credential(s) now held, have you applied for one? Yes No

If yes, what type:

7. Are you or have you ever been a member of the California State Teacher’s Retirement System (STRS)? Yes No

a. Have you ever had a credential suspended or revoked? Yes No

b. Have you ever been dismissed or asked to resign from any teaching position? Yes No

c. Should the answer be yes on 7a. or 7b., please explain in the space below:

8. Use of languages other than English:

Speak Read Write

State Language Degree of Fluency

Speak Read Write

State Language Degree of Fluency

9. Have you taken and passed CBEST? Yes No

(Attach copy of CBEST verification)

10. EDUCATIONAL WORK EXPERIENCE (list most recent position first): If space provides, in addition to other than regular teaching experience, report applicable student teaching experience. Indicate type: regular, substitute, or student teaching.

Type / From / To / Grade/Subject/Position / School / District / District Address

11. NOTE: Check here ( ) if you have qualifications that you feel would enhance your ability to work with multi-cultural programs and/or groups.

Type of qualifications:

12. All other related work experiences other than teaching or administration during the last 10 years.

Employer / Address, City, State, Zip / Type of Work / Dates / Salary

13. Please add any other information or comments which you feel will be of interest or value to those responsible for the selection of teachers. (Example: Your philosophy of education, any special training or abilities, etc.)

14. COLLEGE/UNIVERSITY EDUCATION

Name and Location / Attended
From / To / Graduation
Date / Degree / Major(s) / Minor(s)

Number of semester/quarter units of graduate work after BA or BS degree:

Number of units beyond MA or MS:

15. My placement papers are on file with the following placement office(s):

Institution/Agency / Address / City / State / Zip code

Registered Name:

16. List professional references, especially from immediate supervisors. Include those who have a personal knowledge of your teaching or other educational work experiences, e.g., superintendent, principal, supervisor, and student teaching master teachers. (Respond even if you have placement papers on file).

Name / Position / Address / Phone Number

17. If an elementary teacher applicant, please answer the following questions:

·  Do you play the piano well enough for kindergarten and elementary grades? Yes No

·  Do you play any other instruments suitable for classroom instruction? Yes No

·  Please specify instruments

·  Can you teach music in your own room? Yes No As a special subject? Yes No

18. Have you ever been convicted for anything other than a minor traffic violation? Yes No

If yes, please list all convictions and dates below.

(This information will not necessarily disqualify you for this position however; failure to admit is cause for disqualification.)

19. Do you have relatives presently working for the Garvey School District? Yes No

Name / Position / Relationship to you

20. Do you have a valid California driver’s license? (applicable only if job related) Yes No

If no, can you acquire a California driver’s license if needed for employment? Yes No

California Driver’s License Number: Expiration Date:

I certify that all information and/or statements are true to the best of my knowledge. I understand that false information and or statements shall be sufficient cause for removal from consideration, as an applicant, or dismissal as an employee.

Signature: Date:

How did you hear of this opening?

Return Application to: GARVEY SCHOOL DISTRICT, Human Resources Department – 2730 N. Del Mar Avenue, Rosemead, CA 91770

Telephone: (626) 307-3486 FAX: (626) 307-3492

Business Hours: 8:00 a.m. – 5:00 p.m. (Monday – Friday)

The Governing Board prohibits unlawful discrimination against and/or harassment of district employees and job applicants on the basis of actual or perceived race, color, national origin, ancestry, religious creed, age, marital status, pregnancy, physical or mental disability, medical condition, veteran status, gender or sexual orientation, at any district site and/or activity. (Board Policy 4030)

AFFIRMATIVE ACTION/EQUAL OPPORTUNITY EMPLOYER

(Revised 6/09)