Form Ps 002B – Fill Out and Use This PDF

INSTRUCTIONS FOR COMPLETION AND SUBMISSION: Complete this application by providing all information requested. Include fees and Fee Sheet (PS-186), educational validation documents such as diplomas, certificates, and transcripts; "Professional Conduct" section documentation, if applicable; and for School Directors only, signed Director’s Statement (PS-001Z).

Send the original of this completed application to TWC, keeping one copy for the school’s file and one for the applicant’s records. Original application submissions must be received in a timely manner which allows for up to ninety (90) days with an acting director. Resubmissions to correct deficiencies must be received within 15 days of notification of said deficiencies in order to avoid payment of an additional $20.00 fee.

Make checks payable to TWC Career Schools and Colleges and mail completed applications, documentation, fee and Fee Sheet to the Texas Workforce Commission, Career Schools and Colleges - Controller (if money is enclosed) or Texas Workforce Commission, Career Schools and Colleges, Room 226T (if no money is being sent) - 101 East 15th Street - Austin, Texas 78778-0001.

(Please type or print legibly)

2.

School #S

School Name

School Location (physical address)

School Mailing Address

School e-mail

Phone

School FAX

Toll-free #

School Director

3.

Applicant’s Legal Name

SSN

First

Middle

Last

Applicant’s Date of Birth (mm/dd/yyyy)

Date of Employment at this School (mm/dd/yyyy)

Applicant’s Home Address

Phone

4.

Teaching Credentials (Type)

(State)

(No.)

5.Current Certificates or Occupational Licenses (other than teaching credentials):

TypeIssued byNo..

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8.Professional Conduct: (***Attach a separate typewritten page, signed by the applicant and school official certifying the truth and accuracy of all statements, to fully explain any circumstance resulting in a “YES” answer to the questions below:

I certify that the following statements are true and correct. I agree, consent, and direct that any person or entity maintaining information in any form relating to my criminal history shall release all information upon the request of the Texas Workforce Commission. I further agree and permit the Texas Workforce Commission to obtain from any person or entity information relating to my personal background, reputation, and character, and expressly direct that any such person or entity release such information upon the request of the Texas Workforce Commission. I release, discharge and exonerate the Texas Workforce Commission, its agents or representatives, and any person or entity so furnishing information from any and all liability of every kind arising. The foregoing consent and release is valid and binding while I am seeking or have received approval under the authority of Chapter 132 of the Texas

Education Code.

	Date (mm/dd/yyyy)
Applicant's Signature		Date

APPLICANT CERTIFICATION: I certify that all the information provided in this application and in the foregoing statements are true and correct.

Typed or printed name of applicant

Applicant's Signature

Date (mm/dd/yyyy)

AUTHORIZATION: As an authorized school official, I have carefully reviewed and verified the qualifications of the proposed employee and his/her statements contained on this application. To the best of my knowledge and belief, he/she is qualified for the position as required by the rules for Texas Career Schools and Colleges, Section 807.62(b).

	Typed or printed name of Authorized School Official			Title of Authorized School Official
	Signature of Authorized School Official			Date (mm/dd/yyyy)

Once you complete this application and provide all the information requested, make copies for the school and applicant files; then make checks payable to TWC Schools and mail the original application, fees and fee sheet form PS-186, educational validation documents such as diplomas, certificates, and transcripts, Director’s Statement form PS-001Z , and, if warranted, verified typewritten explanations and supporting documents for “Yes” answers in the “Professional Conduct” section to Texas Workforce Commission, Career Schools and Colleges - Controller (if money is enclosed) or Texas Workforce Commission, Career Schools and Colleges, Room 226T (if no money is being submitted) - 101 East 15th Street - Austin, Texas 78778-0001

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The Director of Education must qualify to teach at least one subject offered by the school. Please consult page 7 of the current

Instructor Application (PS-002) to identify the appropriate educational qualifier, and include below with accompanying supportive information requested. Directors and/or DOEs who will actually teach must submit Instructor Application, Form PS-002.

* Instructor Qualifier from page 7 of the current Instructor Application (PS-002):

9.SUBJECT APPROVAL (Please follow carefully the instructions for completing this section.)

In the blanks entitled “Subject(s) to be taught” list the individual subject(s) exactly as they appear in the school catalog.

In the “Applicant's Educational History” section, list the postsecondary courses successfully completed that relate to the “Subject(s) to be taught” you have listed, identifying the number of hours completed for each course.

In the “Applicant's Work Experience” section, include all the information requested regarding your work and/or teaching experience within the last ten years only and that is related to the “Subject(s) to be taught.”

Subject(s) to be taught (as named in the school catalog):

Applicant's Educational History (postsecondary courses successfully completed and related to the above subjects):

Course(s) Taken	No. of Hours		Clock Hrs.			Semester Hrs.			Quarter Hrs.
			(	)		(	)		(	)
			(	)		(	)		(	)
			(	)		(	)		(	)

10.Applicant's Work Experience: Please include all the information requested regarding your work and/or teaching experience within the past ten years and related to the “Subject(s) to be taught” you have listed above.

Job Title

Dates of Employment: From

Thru

TOTAL

(mm/yy)

(mm/yy)

(years/months)

Name of Employer

Address

Name of Supervisor

Area Code & Phone

Describe the work you performed

(Copy this page if additional space is needed to include the information required by the Instructor Qualifier you listed above.)

__________________________________________________________________________________________________________________________

Completed forms, inquiries, or corrections to the individual information contained in this form shall be sent to the TWC Career Schools and Colleges, 101 East 15th Street, Room 226T, Austin, Texas 78778-0001, (512) 936-3100. Individuals may receive and review information that TWC collects about the individual by emailing to open.records@twc.state.tx.us or writing to TWC Open Records, 101 E. 15th St., Rm. 266, Austin, TX 78778-0001.

__________________________________________________________________________________________________________________________

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