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

TEACHING ASSISTANT 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)

Present Position

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

If not, why?

Are you registered with Civil Service? Yes No

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

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

Yes No If no explain:____________________________________________________

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	Subject	1^st Choice	2^nd Choice
A.W. Becker			Middle School			Elementary
P.B. Coeymans			High School			Secondary

CERTIFICATION Are you certified as a teaching assistant? Yes No

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

STATE

TITLE

TEMP.

CONTIN.

NUMBER

DATE ISSUED

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

IN UP STATE NEW YORK’S CAPITAL DISTRICT

EDUCATIONAL AND/OR PROFESSIONAL TRAINING

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

RECORD OF WORK EXPERIENCE

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

Dates		Name & Address of Employer	Position	Salary	Reason for Leaving
From	To

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

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.

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 ability. Please forward two letters of recommendation to:

Leslie Long

26 Thatcher Street

Selkirk, NY 12158

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

When could you start work?

Applicant’s Signature Date