Pullman School District No

PULLMAN SCHOOL DISTRICT NO. 267

240 SE Dexter Street • Pullman, WA 99163

Personnel Office (509) 332-3584 • FAX (509) 334-0375

APPLICATION FOR CERTIFICATED EMPLOYMENT

DATE:

POSITION (S) FOR

WHICH YOU ARE

APPLYING:

PERSONAL INFORMATION

Last Name / First Name / MI
Other Names Used / Social Security Number
Temporary Address / City / State / Zip
Permanent Address / City / State / Zip
Telephone / Message Number / Email

CERTIFICATION AND ENDORSEMENTS (please indicate if certification is pending & date of application)

Type / Number / Date Issued / Expiration Date / Endorsements
Test Scores(West-B, West-E/Praxis II), if applicable - please include copy of test result reports with your application

EDUCATION

EDUCATION AND TRAINING (list most recent first)
Name of Institution
City, State / Dates Attended
Mo/Yr to Mo/Yr / Degree / Date of Degree / Major / Minor / GPA
PROFESSIONAL PREPARATION (please check all that apply and indicate your preparation)
Topic / Dates / Indicate preparation/experience
State Assessments
Reading Instruction
Writing Instruction
Mathematics Instruction
Science Instruction
Special Education and
504 Accommodations
Highly Capable -
Advanced Placement
Differentiated Instruction
Technology
Other professional
preparation (please list):
Cultural Competence and Responsiveness

COACHING/ADVISING STUDENT GROUPS(please list activities of interest and background in said activity - coaching, academic teams, clubs, tutoring)

EMPLOYMENT EXPERIENCE

CERTIFICATED CONTRACTED EXPERIENCE(list most recent first)

District Name
Phone Number / Address
City, State, Zip / Dates
Mo/Yr to Mo/Yr / Position Title
(Grade (s) and/or subject (s) taught) / Reason for Leaving
CERTIFICATED SUBSTITUTE EXPERIENCE(include prior PullmanSchool District experience)
District Name
Phone Number / Address
City, State, Zip / Dates
Mo/Yr to Mo/Yr / Position Title
(Grade (s) and/or subject (s) taught) / Reason for Leaving
STUDENT TEACHING EXPERIENCE
District Name
Phone Number / Address
City, State, Zip / Dates
Mo/Yr to Mo/Yr / Position Title
(Grade (s) and/or subject (s) taught) / Master Teacher/
Principal

OTHER EMPLOYMENT EXPERIENCE(list most recent first)

Employer
Phone Number / Address
City, State, Zip / Dates
Mo/Yr to Mo/Yr / Position Title / Reason for Leaving

MILITARY EXPERIENCE

Branch of Service / Duties / Dates
Mo/Yr to Mo/Yr / Total Years
REFERENCES(professional only – do not list friends or relatives)
Name / Position / Relationship
Address , City, State / Zip / Telephone
Home:
Business:
Name / Position / Relationship
Address , City, State / Zip / Telephone
Home:
Business:
Name / Position / Relationship
Address , City, State / Zip / Telephone
Home:
Business:
Name / Position / Relationship
Address , City, State / Zip / Telephone
Home:
Business:

•I hereby authorize the PullmanSchool District to make any investigation of my personal or employment history and authorize any former employer, person, or organization to give PullmanSchool District any information regarding me. I release the PullmanSchool District, its employees and/or agents and all providers of information from any liability as a result of furnishing and receiving this information.

• I certify that the information presented in this application is true and complete to the best of my knowledge, and I have read and understand that I have authorized the district to conduct reference checks. I further agree that if I am employed, I will provide verification of my certification, education, and experience. I understand if I am employed, false statements on this application may be cause for dismissal.

Signature Date

PULLMANSCHOOL DISTRICT MAINTAINS A TOBACCO FREE AND DRUG FREE ENVIRONMENT

PULLMANSCHOOL DISTRICT IS AN EQUAL OPPORTUNITY EMPLOYER

The Pullman School District does not discriminate in any programs or activities on the basis of sex, race, creed, religion, color, national origin, age, veteran or military status, sexual orientation, gender expression or identity, disability, or the use of a trained dog guide or service animal and provides equal access to the Boy Scouts and other designated youth groups. The following employee has been designated to handle questions and complaints of alleged discrimination: Assistant Superintendent, Pullman School District Administrative Offices, 240 SE Dexter Street, Pullman, WA 99163, (509) 332-3144, . Applicants with disabilities may request reasonable accommodations in the application process by contacting the Human Resources Manager at (509) 332-3584.