*Please submit three Letters of recommendations with your application and a cover letter.
Name / DateAddress / Home phone
Business phone
Cell phone
CALIFORNIA CREDENTIALS and SUBJECT AREA AUTHORIZATIONS NOW HELD
Credential / Subject Area /
Supplementary Authorization / Expiration Date
Name of California
Teaching Credential applied for: / Date of Application:
Are your credentials recorded in the Ventura County Schools Office? / YES ______NO ______
OUT OF STATE CREDENTIALS NOW HELD
State / Credential / Subject Area /
Supplementary Authorization / Issue Date /
Expiration Date
/
/
CBEST / CLAD / BILINGUAL (BCC or BCLAD) AUTHORIZATIONS
Have you passed the CBEST? / YES ______NO ______ / PENDING - Date Taken
Are you proficient in a language other than English? / YES ______NO ______ / LANGUAGE
List BCC, BCLAD, LDS, ESL, CLAD, or SB1969 Credentials Held
List parts of Bilingual (BCC or BCLAD) Certificate exam you have passed
EARNED ACADEMIC DEGREES FROM ACCREDITED COLLEGES AND UNIVERSITIES
List all Educational Institutes attended in order of attendance
Institution / Location
City and State / Date
From / Date
To / Major / Minor / Degree / Date
TOTAL Upper Division Semester Units earned AFTER Bachelor’s Degree? ______
(1 Quarter Unit = 2/3 Semester Unit)
EXPERIENCE RECORD
List last position first. Indicate full time, part time, substitute, or student teaching. Report all paid teaching experience. Account for each year since you began teaching. (Use separate sheet if necessary).
Month / Year
FROM / School / Grade / Subject
TO / District
FULL TIME / District Address
PART TIME / District City/Zip / Phone / ( )
SUBSTITUTE / Principal / Phone / ( )
Do you have a contract for next year?
Month / Year
FROM / School / Grade / Subject
TO / District
FULL TIME / District Address
PART TIME / District City/Zip / Phone / ( )
SUBSTITUTE / Principal / Phone / ( )
Reason for Leaving
Month / Year
FROM / School / Grade / Subject
TO / District
FULL TIME / District Address
PART TIME / District City/Zip / Phone / ( )
SUBSTITUTE / Principal / Phone / ( )
STUDENT TCHNG / Reason for Leaving
Month / Year
FROM / School / Grade / Subject
TO / District
FULL TIME / District Address
PART TIME / District City/Zip / Phone / ( )
SUBSTITUTE / Principal / Phone / ( )
STUDENT TCHNG / Reason for Leaving
Recent Trainings and /or Workshops related to curriculum development and instructional techniques.
PROFESSIONAL REFERENCES
Include only those who have knowledge of your experience as an educator
(superintendents, principals, and supervisors.)
Name / Position / Phone & Mailing Address
PERSONAL INFORMATION
Have you ever been convicted of ANY misdemeanor or felony except:
-Misdemeanor offense involving 28.5 grams or less of marijuana two or more years ago. / YES / NO
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 left a teaching position prior to the expiration of a contract? / YES / NO
NOTE / If you answered yes to any of the above, please attach a complete and accurate explanation of the circumstances to this form. An answer of yes will not necessarily disqualify you from the position for which application is made, but any failure to respond completely and accurately may result in your not being employed, or if discovered after employment, in your dismissal.
SPECIAL INTERESTS YOU COULD SHARE WITH THE STAFF/STUDENTS
Music? / Art? / Drama?
Physical Education? / Dance? / Other Special Activities?
What Special training have you had in the following areas:
Remedial Reading / Science
Special Education / Mathematics
Foreign Language / Technology
What do you do to keep current with new developments in instruction and/or in the content area in which you teach?
Have you ever supervised a student teacher and/or an instructional aide? If yes, describe your successes & challenges in providing support to these individuals.
What is your vision/experience with team collaboration?
What contributions have you made to the teaching profession? (e.g. research, leadership roles, curriculum development, sharing and teaming with other teachers)
CERTIFICATION OF APPLICANT AND AUTHORIZATION TO RELEASE INFORMATION
I hereby certify that all statements made in this application are true and complete to the best of my knowledge, and authorize investigation of all statements herein recorded. I understand that any false statements or omissions of material facts may subject me to disqualification or dismissal if employed.
As an applicant for a position with the University Preparation School at CSUCI (UPS), I am required to furnish information and references for use in determining my qualifications. I understand that UPS may conduct an investigation of my work and/or personal history and that it may verify all data given in my application for employment, related papers, and/or oral interviews. I further understand that any and all of the references that I have provided to UPS, either in writing or otherwise, may be contacted. By signing this release form, I hereby authorize such investigation. In addition, I authorize any previous employer and/or any other references to release and fully disclose to any agent of UPS any information that such person may have concerning me, including information of a confidential or privileged nature, whether or not it is in their records.
I hereby release UPS, previous employers, and/or other references from any liability or damage that may result from furnishing the information requested.
A photocopy of this release form will be valid as an original thereof, even though the said photocopy does not contain my original signature.
Signature of Applicant: ______Date: ______