Oregon Teacher Application – Fill Out and Use

(Note: Individual school districts may require additional information other than that asked for on this application.)

PERSO NAL INFO RMATIO N

Application Date: _______________________________________ Social Security Number ____________________________________________

Full Name ___________________________________________________________			Date of Availability ______________________________
Last	First	Middle	Month	Day	Year

Previous or other surname(s) reflected on employment or educational records ______________________________________________________

Previous Mailing Address ________________________________________________________			Phone (________)_____________________
	Street		❏ phone number is unlisted
______________________________________________________________________________			Msg. Phone (________)________________
City	State	Zip Code	Where you can always be reached
			❏ phone number is unlisted
Permanent Mailing Address ______________________________________________________			Phone (________)_____________________
	Street		❏ phone number is unlisted
______________________________________________________________________________
City	State	Zip Code

Name of contact if other than applicant ______________________________________________________________________________________

Currently under contrac t with another school distric t?	❏ Yes	❏ No
If yes: School District ___________________________________________________		City _________________________________________

Current O regon Teaching License

Type(s) (e.g. Basic D-474, Temporary, etc.) ___________________________________________________________________________

Endorsement(s) (e.g. Physical Education) ____________________________________________________________________________

Authorization(s) (e.g. 018) ________________________________________________________________________________________

Date of Expiration _______________________________________________________________________________________________

Added endorsements expected ____________________________________________________________________________________

If no O regon License, when is it expected? _______________________________

	Month	Year
❏ Full-Time Contract	❏ Part-Tine Contract
❏ Temporary Contract	❏ Substituting	❏ O ther _____________________________________

Personal History

Have you ever:

YES N O

❏❏ • been dismissed from a teaching position?

❏❏ • been asked to resign from a teaching position?

❏❏ • been refused continuing employment as a teacher?

❏❏ • had a teaching license revoked?

❏❏ • been convicted, pled guilty, or pled nolo contendere to a felony?

❏❏ • been convicted, pled guilty, or pled nolo contendere to a crime involving child abuse or sexual abuse?

❏❏ • had a report of child abuse or sexual activities involving a K-12 student or minor filed against you with a school district, Children Services Division, a police agency, or in court?

If yes, please explain. _____________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________

TRAINING AND PREPARATIO N

SPECIAL TRAINING

Please use key to indicate experience or training in any of the following specific classes or workshops.

	KEY: T = Training	E = Experience		T/ E = Both
_____ Authentic Assessment			_____ Equity Awareness		_____ Portfolios
_____ Child Abuse/ Personal Safety			_____ Gifted Education		_____ Remedial Education
_____ Computer Training			_____ Inclusive Education		_____ Signing
_____ Cooperative Learning			_____ Integrated Curriculum		_____ Study Skills
_____ Conduct Disorders			_____ ITIP		_____ Task Writing/ Rubrics
_____ Critical Thinking Skills			_____ Learning Skills		_____ Visual/ Manipulative Math
_____ Current First Aid Card			_____ Middle Level Education		_____ Whole Language
_____ Curriculum Integration			_____ Multi-Age Class		_____ O ther _________________
_____ Developmentally Appropriate Practices			_____ Multicultural Awareness
_____ Drug/ Alcohol Problems			_____ Peer Coaching

EXPERIENCE O THER THAN TEACHING

OTHER LANGUAGES: Please list any foreign language(s) you can use. ____________________________________________________________

❏Fluent skills (speak, read, write)

❏Minimal skills (please list abilities) ________________________________________________________________________________

_________________________________________________________________________________________________________

Actual language training ________________________________________________________________________________________

ELEMENTARY APPLICANTS: Check areas in which you have training or experience to the extent the skill(s) could be used in class. ❏ Play Piano ❏ Teach PE ❏ Teach Art ❏ Teach Vocal Music

PLACEMENT FILE

Do you have current placement file(s)?	❏ Yes ❏ No
I requested a copy of my placement file to be sent to the appropriate school district.		❏ Yes	❏ No

MILITARY EXPERIENCE

Branch of Service

Job Classification

Inclusive Dates

Type of Discharge

Citizenship: Are you a U.S. citizen or otherwise legally authorized to work in the U.S.? ❏ Yes ❏ No

Health: Is your physical/ mental health condition such that you can fulfill the essential job functions of the teaching/ extracurricular work for

which you are applying (either with or without reasonable accommodations)?

❏ Yes ❏ No

APPLICATIO N S

Applications which are forwarded to a school district will remain active at that district for one year. The district will normally keep the application on file for three years. Contact individual districts about procedures for reactivating an application that is more than one year old.

I understand that any omissions on this application may prevent my application from being evaluated or referred to an individual school district. I authorize any school district to which this application is submitted to obtain information about my criminal records. I authorize all governmental agencies to provide information about my criminal records to the school district. I verify that all information on this employment application is true and complete . I understand that any misrepresentation, falsification, or omission on this application or on other documents submitted to the school district will be sufficient cause for this application not to be considered by the school district, not to be referred to a school district, or for discharge if I have been employed.

AUTHO RIZATIO N TO O BTAIN AND RELEASE INFO RMATIO N

I authorize any O regon school district for which I have completed an employment application to check my references, to obtain information from my prior employers and educational institutions, and to take other actions to investigate any information provided in my employment application, and to obtain information relevant to evaluating my qualifications and fitness for a teaching position. I authorize my listed references, past employers and educational institutions, and anyone else who has information about my work history, education qualification or fitness, to provide such information to any school district for which I have completed an employment application. I release the school district and all persons providing information to the school district from any liability whatsoever for obtaining and providing that information, regardless of the results.

Signature ______________________________________________________________________________ Date _____________________________________

O REGO N

STATEWIDE TEACHER APPLICATIO N

AN EQ UAL O PPO RTUNITY EMPLOYER

EQ UAL O PPO RTUNITY INFO RMATIO N

O regon school distric ts are equal opportunity employers and comply with all applicable state and federal statutes and regulations in employment and school distric t programs.

Drug-free Workplace

O regon school districts are committed to maintaining drug-free workplaces and comply with all applicable state and federal statutes and regulations in employment and school district programs.

______________________________________________________________________________________________________________________

Name

______________________________________________________________________________________________________________________

Position for which you are applying

If you prefer not to provide the information requested below, please sign and date .

_____________________________________________________________________	_____________________________________________
Signature	Date

VO LUNTARY INFO RMATIO N

This information is voluntary and is collec ted for Equal Employment O pportunity reporting purposes. This form will be physically separated from your other application materials and will not affec t the application process in any manner. Should you prefer not to provide this information, there will be no effec t on your application.

Sex

❏Female

❏Male

Date of Birth ______/ ______/ ______

Race or Cultural Group (Check one only)

❏American Indian/ Alaskan Native

❏Asian/ Pacific Islander

❏White

❏Black

❏Hispanic

❏O ther ____________________________________

W hen this page is forw arded to an individual school district, the receiving district w ill rem ove this page so as to allow the collection of data.