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NCLB COMP ______________ REVIEWED _______________ INTERVIEWED ___________ 15579 8th Street SENT LETTER ____________ Victorville, CA 92395 OFFER CONTRACT ________ CLASS ______ (760) 245-1691 STEP ______ www.vesd.net APPLICATION FOR CERTIFICATED EMPLOYMENT SPEECH PATHOLOGIST I. PERSONAL INFORMATION LAST FIRST HOME PHONE MI: NAME: NAME: MAILING ST/ CELL PHONE STREET CITY ADDRESS: ZIP PHYSICAL ST/ EMAIL STREET CITY ADDRESS: ZIP II. POSITION PREFERENCES (Check) (Prioritize) (Yes or No) Classroom Teacher Kindergarten Traditional (Sept-Jun) Bilingual Grades 1-2 Year Round (Jul-Jun) Special Education Grades 3-4 Speech Grades 5-6 Are you currently employed? Date available III. PROFESSIONAL REFERENCES (include your current or most recent supervisor) DISTRICT OR COLLEGE NAME POSITION CITY AND STATE TELEPHONE DISTRICT OR COLLEGE NAME POSITION CITY AND STATE TELEPHONE DISTRICT OR COLLEGE NAME POSITION CITY AND STATE TELEPHONE DISTRICT OR COLLEGE NAME POSITION CITY AND STATE TELEPHONE PLEASE SUBMIT YOUR PLACEMENT FILE OR THREE LETTERS OF RECOMMENDATION VII. ADDITIONAL INFORMATION YES NO A. HAVE YOU EVER HAD A CREDENTIAL SUSPENDED OR REVOKED? If yes, please explain where and why B. HAVE YOU EVER BEEN CONVICTED OF A FELONY? Conviction will not necessarily disqualify an applicant from employment C. HAVE YOU EVER LEFT A TEACHING POSITION PRIOR TO THE EXPIRATION OF A CONTRACTUAL AGREEMENT? If yes, please explain where and why D. ARE YOU RELATED TO ANY PRESENT EMPLOYEE OF THIS DISTRICT? If yes, give name and position E. HAVE YOU EVER BEEN EMPLOYED BY THIS DISTRICT? If yes give location and date employed. F. ARE YOU CURRENTLY UNDER CONTRACT? If yes, give location and date of expiration. G. DO YOU OBJECT TO HAVING YOUR PRESENT EMPLOYER CONTACTED? H. ARE YOU A CURRENT MEMBER OF A CALIFORNIA RETIREMENT SYSTEM? (STRS) (PERS) I. HAVE YOU BEEN ISSUED AN NCLB CERTIFICATE OF COMPLIANCE? J. DO YOU HOLD NATIONAL BOARD CERTIFICATION? K. CAN YOU PROVIDE DOCUMENTS TO VERIFY YOUR IDENTITY AND AUTHORIZATION TO WORK IN THE UNITED STATES? Documents may include, but are not limited to Birth Certificate or Social Security Card and Driver’s License; Citizenship or Naturalization certificate; Passport or Alien registration card; other approved documents. CREDENTIALS HELD – PLEASE PROVIDE COPIES Name of Credential Subject/Authorization Date Issued/State Expiration Date CREDENTIALS ANTICIPATED Name of Credential Qualified Now/Or Anticipated Completion Date Institution Name Yes No Yes No Have you taken the following: CBEST PASSED SUBJECT MATTER EQUIVALENCY EXAM CSET/MSAT/NTE PASSED CERTIFICATION OF APPLICATION Read Before Signing: I certify that the statements I have made in this application are true. Further, I authorize the Victor Elementary School District to verify the foregoing and any other information which might assist the District to determine my qualifications for employment. I hereby release the Victor Elementary School District and my former employers from any liability which may result from such investigations. If, upon investigation, anything in the application is found to be untrue, I understand that any false statements of material facts can cause forfeiture on my part to any employment with the Victor Elementary School District. Date: Legal Name: Signature VICTOR ELEMENTARY SCHOOL DISTIRCT IS AN AFFIRMATIVE ACTION/EQUAL OPPORTUNITY EMPLOYER: The law prohibits discrimination on the basis of sex, race, color, religious creed, national origin, ancestry, physical handicap, medical condition or age in its employment practices. Victor Elementary School District also maintains a smoke-free workplace. IV. EDUCATION Name of Institution Location From To Degrees Earned Major (City/State) (Date) (Date) Date Earned Number of semester units of graduate work beyond BA or BS degree Number beyond MA or MS (1 QUARTER UNIT = 2/3 SEMESTER UNIT) Graduate work is defined by a given college or university acceptable toward meeting requirements for an advanced degree or credential and taken after the date the BA/BS degree is received. Transcripts of all college and university work are required before a pay warrant can be issued. V. EXPERIENCE List only experience applicable to position for which you are applying, the most recent first STUDENT TEACHING EXPERIENCE: Dates Grades Master Teacher College District City/State From-To Taught Supervisor TEACHING EXPERIENCE UNDER CONTRACT: (Do Not List Substitute Teaching) Dates Grades Immediate District City/State Reason for Leaving From-To Taught Supervisor TOTAL YEARS TEACHING EXPERIENCE UNDER CONTRACT EDUCATIONAL EXPERIENCE OTHER THAN CONTRACT TEACHING: (Include part-time and Substitute Teaching here) Dates District City/State Type of Work From-To EXPERIENCE OTHER THAN TEACHING: (Optional) Dates District City/State Type of Work From-To VI. QUESTIONS Please respond to the following questions in the space provided. (Your own handwriting is preferred.) 1. What do you consider to be some of your highest motivations for choosing to become a Speech pathologist? 2. What kind of relationship do you establish and maintain with students? Why? 3. What do you most want to achieve in the kind of relationships you build with students? 4. What do you especially think about as you begin to design independent or small group lessons? 5. What would a supervisor observe when you are providing services to students? 6. How do you want students to be different as a result of their experiences with you? 7. What major strategies do you most employ to deliver instruction to make a difference in the lives of students? 8. Why are you interested in Victor Elementary School District?
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