FOR OFFICE USE ONLY: Date: New York State Law Prohibits

Sent for Received Discrimination Because of Race,

Letter of Application Color, Creed, Nationality, Sex, Age

References Disability or Marital Status

No Opening Letter

Position Filled Letter

SUBSTITUTE TEACHING APPLICATION FOR POSITION IN

RAVENA-COEYMANS-SELKIRK CENTRAL SCHOOL

26 Thatcher Street, Selkirk, NY 12158

(518)756-5200

Fax: (518)767-2644

Date Name Social Security No.

Present Address Tel. No.

Permanent Address Tel. No.

(if different from above)

NYS Teacher’s Retirement No. (if applicable)

Present Position

Do you have a legal right to work in the United States? Yes No

If not, why?

Have you been fingerprinted through the State Education Dept. before? Yes No

Are you able to perform the duties of a teacher, with or without reasonable accommodations?

Yes No

POSITION DESIRED (Please number specific areas according to preference; 1-1^st choice, 2-2^nd choice.)

Elementary	1^st Choice	2^nd Choice	Secondary	1^st Choice	2^nd Choice	Subjects	Substitute	1^st Choice	2^nd Choice
Primary			Jr. High				Elementary
Int.			Sr. High				Secondary

Other Subjects

CERTIFICATION Are you certified Yes No

List below all teaching certificates which you now hold, including any out of state.

STATE

TITLE

PROV.

PERM.

NUMBER

DATE ISSUED

LEVEL OR SUBJECT

List the types of any certificates for which you are working and the date you expect to receive them.

Have you received prior tenure? Yes No

Where When

Area

IN UP STATE NEW YORK’S CAPITAL DISTRICT

EDUCATIONAL AND/OR PROFESSIONAL TRAINING

Wherever space is insufficient, use last page

Name School or Institution, City & State	Major	Degree or Diploma	Date	Time Spent	Number of Credits
College(s)
Graduate Work

Please check appropriate box

1^st yr. student 2^nd yr. student 3^rd yr. student 4^th yr. student Post Graduate

RECORD OF WORK EXPERIENCE

Please list in strict chronological order all work experience including present position, student and regular teaching, acquired since graduation from high school including military service.

Dates		Name & Address of Employer and/or School District and School Bldg.	Business or Grade or HS Subjects	Salary	Reason for Leaving
From	To

Number of days absent past three years

Enumerate other experiences which may be related to teaching or from which you feel you gained something of value to teaching

Professional contributions (list any articles, books, etc., that you have had published.

What activities, clubs or athletics did you participate in while in high school and college?

Current Interests:

List any awards or honors you received while in high school, college or on the job.

What foreign languages do you speak?

List any professional organizations of which you are a member:

REFERENCES: Give at least two references, including those who have firsthand knowledge of your character, personality, scholarship and teaching ability. Please forward two letters of recommendation to:

Greg Chase

26 Thatcher Street

Selkirk, NY 12158

References MUST be received in order for application to be processed.

When could you come for an interview?