STANDARD APPLICATION FOR CERTIFIED PUBLIC SCHOOL EMPLOYMENT

Date/s available for interviews:______

Date available for employment:______

  1. Personal

M______

FirstMiddleMaiden NameLast Name

Current Address______Phone ( )______

CityZip code

Permanent Address______Phone ( )______

CityZip code

Are you a U.S. Citizen? Yes_____ No_____ S.S.#______Draft or Military Status______Total # of Teaching______

2. Position/s for which you are applying______

Subject/s, grade level/s, or non-teaching position/s (according to preference):

First preference______Second ______Third______

Other subjects you are qualified to teach; activities to direct; or positions to fill.

______

3. California credentials or permits now held:

Type______Expires______

Type______Expires______

California teaching permit or credential applied for:

Name______Date of Application: ______

Exams taken & Date passed:

CBEST____ (Date______); CSET____(Date______); RICA____ (Date______); MSAT____(Date______); Praxis____(Date______)

Are you or have you ever been a member of the Public Employees Retirement System? Yes ______No ______

4. Has your credential ever been suspended or revoked? Yes______No ______

Have you ever been dismissed, or asked to resign from any teaching position? Yes ______No______

Have you ever been arrested for anything either than a minor traffic violation? Yes ______No ______

For every question answered “Yes”, explain in writing the circumstances and attach the statement to this form.

  1. Teaching experience (List last position first. If more than five years, list positions for last five years; if none, report student teaching experience. Indicate type – regular, substitute, or student teaching.)

Type / Dates
From To / Grades or
Subjects / School / District / District Address

5a. NOTE: Check here if you have qualifications which especially equip you to work with culturally different and/or minority groups and multi-ethnic programs.

5b. Work experience other than teaching:

  1. College or university education;

Name and Location of each Institution attended / Attended / Graduated / Major(s) / Minor(s)
From / To / Date / Degree

Number of semester units of graduate work beyond BA or BS degree _____ Number beyond MA or MS______1 Qtr.Unit = 2/3 Semester Unit

  1. My placement papers are on file with the following placement office: ______

Address______City______State______Zip Code______

Under the name of:______

  1. Professional references, if not registered with a placement office (include only those who have knowledge of your teaching experience; (e.g., superintendents, principals, supervisors, and student teaching master teachers)

Name / Position / Address

I, HEREBY CERTIFY, that all statements made herein are true and correct to the best of my knowledge and authorize investigation of all statements herein recorded. I release from all liability persons and organizations reporting information required by this application.

______

Signature of ApplicantDate

This organization is an “Equal Opportunity Employer” and does not discriminate on the basis of race, color, national origin, creed, age, gender or disability. Inquires regarding compliance procedures may be directed to our personnel office.

This organization complies with “Americans with Disabilities Act”. Persons with a disability who may need some accommodation in the hiring process should contact our personnel office.

This organization is a “Drug and Tobacco-Free”Workplace

This organization requires a successful candidate to provide it with employment eligibility and verification of a legal right to work in the United States in compliance with the “Immigration Reform and Control Act”.