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					                                    North Carolina Teacher Corps Application
                                     Section I Biographical Information
Last Name                                            First Name                                    M.I.

Primary Phone (    )                                 Mobile Phone (    )

Street Address                                       City                  State                   Zip

E-mail Address

Are you a U.S. citizen         Yes       No
Do you claim legal residence in NC for tuition purposes?          Yes       No (NC Teacher Corps tuition assistance
is based on in-state tuition rates. Individuals classified as out-of-state residents would be responsible for
payment of the difference between in-state and out-of-state tuition.)

                                        Section II Education History
       Name of              City, State      Dates of       Degree                 Major         Overall GPA
  College/University                       Attendance      Awarded
                                          Month Years      (BS, BA,
                                                             etc…)




             Additional Coursework/Subject Area (s) in which you have 24 or more semester hours:
                        Subject                                            Number of hours




                                       Section III Employment History
                           List most recent first and add additional sheets if necessary
       Employer                City, State          Dates of               Job Title       Reason for Leaving
                                                  Employment
                                                 From      To
                   Section IV Civic/Leadership/Teaching Related Experience
       Name of Organization                Dates of        Description of                 Description of
                                    Participation/Service     Activity                      Leadership
                                     From           To                                   Roles/Experience




                                    Section V General Questions
   Please mark either yes or no for the following questions. If you mark yes, please provide an
      explanation here or attach additional pages. (A background check will be conducted)
                                                          Yes No               Explanation
1. Have you ever been suspended, dismissed, fired, or
   discharged from a position of employment?
2. Have you ever been asked to resign from a position of
   employment?
3. Have you ever been convicted or pleaded nolo
   contendere (no contest) to any violation of the law other
   than a minor traffic ticket?
4. Do you have any criminal charges or procedures
   pending?

                                  Section VI Reference Requirements

Please Submit 3 Recommendation Forms (Attached).References should include individuals from a
variety of fields (for example not all college professors or personal references) that can attest to your
academic work, your leadership experience, and your character


                                   Section VII Statement of Interest

   On a separate page, please submit a statement of interest including the following:
          Describe your interest in teaching in a high needs school
          Describe skills you have to offer as a teacher
          Describe your ability to overcome challenges


                                   Section VIII Verification of Information
    I hereby certify that the information provided is accurate and complete. I understand that falsifying
    or withholding information in completing this application constitutes my ineligibility for this program.

Applicant’s Signature: _____________________________________________ Date: ____________

                 North Carolina Department of Public Instruction
               Division of Educator Recruitment and Development
                               NC Teacher Corps
6330 Mail Service Center Raleigh, NC 27699-6330 theresa.perry@dpi.nc.gov

				
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posted:9/14/2012
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