LICKINGCOUNTY

EDUCATIONAL SERVICECENTER

675 Price Rd., Phone: 740-349-6084

Newark, Ohio 43055

2006-2007 APPLICATION FOR SUBSTITUTE TEACHING

Name: ______

Address: ______

(City) (State) (Zip)

Phone: ______Soc. Sec. No.: ______

PLEASE CHECK THE DISTRICTS IN WHICH YOU WOULD BE WILLING TO SUBSTITUTE:

Johnstown-Monroe LickingHeights North Fork Southwest Licking

Lakewood LickingValley Northridge

PLEASE CHECK THE LICKING COUNTY ESC CLASSES YOU WOULD BE WILLING TO SUBSTITUTE IN:

(Multiple Disabilities (MD), Emotional Disturbance (ED) & Preschool classes) - Check appropriate classes :

□ Granville Elm (MD)□ LickingValley H.S. (MD) □ The Citadel (MD)

□ Granville H.S. (MD)□ Utica Elm (MD) □ Alexandria Elm (ED)

□ Garfield Elm (MD)□ Utica H.S. (MD) □ LickingHeights Central (ED)

□ Stevenson Elm (MD)□ Alexandria Elm (MD) □ Licking Heights H.S. (ED)

□ Madison Elm (MD)□ Northridge M.S. (MD) □ The Citadel (ED)

□ LickingValley M.S. (MD)□ Kirkersville Elm (MD) □ Preschool – 119 Union St.Newark

TYPE OF CERTIFICATE (s) – DATE OF ISSUANCE ______

(Temp.; 4-yr. Prov.; 8-yr. Prof.; Perm.) CERTIFICATE EXPIRES (Year?) ______

REQUIREMENTS FOR NEW SUBSTITUTE TEACHERS and CURRENTSUBSTITUTE TEACHERS:

  1. Copy of TB Test result within the last 90 days (applies if you did not sub for us last year).
  2. Copy of current OHIO Teaching Certificate – Contact our office for an application if you have not yet applied.
  3. Fingerprint Results within the last year (does not apply if you were asub for us last year and a new certificate is not needed).
  4. Copy of a Sub Training Class Certificate is required for new substitutes without experience who hold a bachelor’s degree in areas other than education.

Have you substituted for us before? _____ Yes When? (year) ______, No ______

Have you had previous teaching/sub experience? ______Where? ______

If you haven’t had previous teaching/sub experience, have you attended the sub training class? ______

Are you currently retired and receiving STRS Benefits? ______

(Please complete next page)

Page 2 – Substitute Form

REFERENCES: Names and address of two educators who would be familiar with your teaching experiences.

______

______

Have you ever been Non-renewed? ____ Suspended? ____ Terminated? ____ Rif’ed? ____

Have you lived in only the state of Ohio for the past 5 consecutive years? Yes _____ No _____

Have you ever been convicted of any of the following: a) a misdemeanor that would be a felony on the second offense; b) any sex offense; c) any offense of violence; d) any theft offense; e) any drug abuse offense?

Yes _____ No _____

If yes, please explain nature and date(s) of occurrence(s):

It is understood and agreed that the LickingCountyEducationalServiceCenter may contact former employer(s) for verification of any employment history and the Bureau of Criminal Identification and Investigation (BCII) for a background check and I hereby consent to such inquiries.

I further understand that falsification of any and all information on this application shall result in my being disqualified from employment or in my employment being terminated. By affixing my signature, I agree to the conditions listed on this application and will, if employed, tender my resignation of employment should I fail to fulfill these conditions.

SIGNATURE ______DATE ______

An Equal Opportunity Employer

NOTE: A new application must be filed with this office to be placed on the substitute list for the ensuing school year.