Standard Pa Application – Fill Out and Use

STANDARD APPLICATION

For Teaching Positions in Pennsylvania Public Schools

(PLEASE PRINT OR TYPE)

POSITION(S) DESIRED

NAME

LAST		FIRST	MIDDLE		PROFESSIONAL PERSONNEL ID
PRESENT ADDRESS
			STREET		(AREA CODE) TELEPHONE
		CITY	STATE		ZIP CODE
PERMANENT ADDRESS
			STREET		(AREA CODE) TELEPHONE
		CITY	STATE		ZIP CODE

E-MAIL ADDRESS (IF AVAILABLE)

LIST, IN ORDER OF PREFERENCE, THE GRADES, SUBJECTS AND/OR POSITIONS FOR WHICH YOU ARE APPLYING:

1.	2.		3.

CERTIFICATION

(LIST ALL AREAS IN WHICH YOU HOLD VALID PENNSYLVANIA AND/OR OUT-OF-STATE TEACHING CERTIFICATES. NOTE: APPLICANTS HOLDING A CERTIFICATE FROM ANOTHER STATE MUST OBTAIN A PENNSYLVANIA CERTIFICATE IN ORDER TO TEACH IN PENNSYLVANIA PUBLIC SCHOOLS.)

PDE 353A (12/03/13)

1

EDUCATIONAL BACKGROUND

MAJOR/

DIPLOMAS,

GRADE POINT

SCHOOL OR INSTITUTION AND LOCATION

DEGREES OR

AVERAGE

MINOR

CREDITS EARNED

(GPA)

HIGH SCHOOL

COLLEGE/UNIVERSITY

COLLEGE/UNIVERSITY

GRADUATE STUDY

GRADUATE STUDY

EXPERIENCE

(PRESENT OR MOST RECENT FIRST)

Dates

Name of Employer and Address

Your Title

From

To

(

Area Code) Telephone:

Work Performed:

Reason for Leaving:

Name & Title of

Final Yearly

Supervisor:

Salary:

Dates

Name of Employer and Address

Your Title

From

To

(

Area Code) Telephone:

Work Performed:

Reason for Leaving:

Name &

Title of

Final Yearly

Supervisor:

Salary:

Dates

Name of Employer and Address

Your Title

From

To

(

Area Code) Telephone:

Work Performed:

Reason for Leaving:

Please list activities that you are qualified to supervise or coach:

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If you have not been previously employed in a teaching position, please complete the following:

STUDENT OR PRACTICE TEACHING

Student Teaching References:

Please attach photocopies of letters of reference and/or evaluations from college/university student teacher supervisor and cooperating teacher(s).

REFERENCES

References should include superintendents, principals or professors who have first-hand knowledge of your professional competence and your personal qualifications. Experienced teachers should include the superintendent and principal of the two most recent schools in which employed. If any person(s) listed should not be contacted for reference at the present time, indicate in the left-hand margin the date contact(s) may be made.

OTHER QUALIFICATIONS

Summarize special job-related skills and qualifications acquired from employment or other experiences (including U.S. military service) and/or state any additional information you feel may be helpful in considering your application, i.e. honors, awards, activities, technology skills or professional development activities:

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GENERAL BACKGROUND INFORMATION

You must give complete answers to all questions. If you answer "Yes" to any question, you must list all offenses, and for each conviction provide date of conviction and disposition, regardless of the date or location of occurrence. Conviction of a criminal offense is not a bar to employment in all cases. Each case is considered on its merits. Your answers will be verified with appropriate police records.

Criminal Offense includes felonies, misdemeanors, summary offenses and convictions resulting from a plea of "nolo contendere" (no contest).

Conviction is an adjudication of guilt and includes determinations before a court, a district justice or a magistrate, which results in a fine, sentence or probation.

You may omit: minor traffic violations, offenses committed before your 18th birthday which were adjudicated in juvenile court or under a Youth Offender Law, and any convictions which have been expunged by a court or for which you successfully completed an Accelerated Rehabilitative Disposition program.

Note: If you answered "Yes" to any of the above questions, please provide a detailed explanation on a separate sheet of paper, including dates, and attach it to this application. Please print and sign your name on the sheet, and include your social security number.

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ACT 34 Clearance (PA State Police Criminal Background Check)

Each applicant must submit with his/her employment application a copy of a Criminal History Record from the Pennsylvania State Police. Prospective employees must submit ORIGINAL report, which may not be more than one (1) year old.

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ACT 114 (Federal Criminal History Record)

Each applicant must submit with his/her employment application a copy of a Federal Criminal Record from the Federal Bureau of Investigation (FBI). Prospective employees must submit ORIGINAL report, which may not be more than one (1) year old.

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ACT 151 Clearance (PA Child Abuse History Clearance)

Each candidate must submit with his/her employment application a copy of an official clearance from the Pennsylvania Department of Public Welfare. Prospective employees must submit ORIGINAL report, which may not be more than one (1) year old.

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ESSAY

Please write an essay as described on page six. For your convenience, you may attach a sheet; however, your essay may not exceed one page. At the bottom of the attachment, please print and sign your name.

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CERTIFICATION AND RELEASE AUTHORIZATION

I certify that all of the statements made by me are true, complete and correct to the best of my knowledge and belief, and are made in good faith. I further certify that I am the sole author of the essay. I understand that any misrepresentation of information shall be sufficient cause for: (1) rejecting my candidacy, (2) withdrawing of any offer of employment, or (3) terminating my employment.

I hereby authorize any and all of my previous employers and/or supervisors to release any and all of my personnel records, and to respond fully and completely to all questions that officials of____________ (school

district) may ask regarding my prior work history and performance. I will hold such previous employers and/or supervisors harmless of any and all claims that I might otherwise have against them with regard to statements made to this school district. I further authorize these officials to investigate my background, now or in the future, to verify the information provided and release from liability all persons and/or entities supplying information regarding my background. However, I do not authorize the production of medical records or other information, which would tend to actually identify a disability nor do I authorize inquiries which would include information related to any medical condition or medical history. Further, I do not waive any rights which I may have under state or federal law related to my right to challenge the disclosure of unlawful or inaccurate information, whether by the school district or by entities or persons providing such information to the school district, including any and all claims concerning allegations of employment discrimination because of race, color, sex, religion, national origin, ancestry, age or disability.

Date	Signature of Candidate (in ink)
	[Must be original]

Pennsylvania school districts shall not discriminate in their educational programs, activities or employment practices based on race, color, national origin, sex, disability, age, religion, ancestry or any other legally protected classification. This policy is in accordance with state and federal laws, including Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, Sections 503 and 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans with Disabilities Act of 1990 and the Pennsylvania Human Relations Act. Information relative to special accommodation, grievance procedure, and the designated responsible official for compliance with Title VI, Title IX, and Section 504 may be obtained by contacting the school district.

PDE 353A (12/03/13)

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ESSAY

We are interested in your ability to organize and express thoughts on a specific topic in a succinct manner. Please select one of the following topics and write an essay in the space provided on this page.

1.The Most Important Qualities of an Outstanding Educator.

2.My Philosophy of Student Discipline.

3.The Importance of Continuing Professional Development and How I Plan to Incorporate It Throughout My Career.

4.Essential Elements of Instruction, Administration or Area of Certification.

5.How Information Technology (i.e., computers, Internet) Can Be Integrated into the Instructional Process and Curriculum.

Signature

Name

Note to applicants: This application can be downloaded from the Department of Education's home page which is accessible at: http://www.state.pa.us.

This application was developed, in accordance with Section 1204.1 of Act 107 of 1996, by the Pennsylvania Department of Education is consultation with organizations representing school administrators, including personnel administrators, teachers and school boards. Questions should be referred to PDE School Services Office at Voice Telephone (717) 787-4860, Text Telephone TTY (717) 783-8445 or FAX (717) 783-6802. If you need accommodation in completing this application, including alternate format, please contact the school district.

PDE-353A (12/03/13)