Last Name First Name Middle Name Maiden by vjz16565

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									Name_________________________________________________________________________________________
       Last Name            First Name             Middle Name                Maiden

Address_______________________________________________________________________________________
            Street              City                      State              Zip

Telephone_____________________________________________________________________________________
            Home              Business/Daytime                Cell

Certification Area Desired________________________________________________________________________

Social Security # ____________________________________

Driver’s License # __________________________ State ___________________ Exp. Date __________________

E-mail Address ________________________________________________________________________________

Date of Birth _____________________ Place of Birth ______________________ Gender ___Male               ___Female

Ethnicity   ___African American     ___American Indian      ___Asian    ___Hispanic    ___White   ___Other

Are you a U.S. citizen? Yes_____ No_____ If not, country of citizenship __________________________________

Are you fluent in English? Yes_____ No_____

Languages spoken fluently other than English ______________________________________________________

Have you ever been arrested that resulted in deferred adjudication, probation or conviction?

Yes_____ No_____ If yes, please explain ______________________________________________________________

Have you ever applied to any other Alternative Certification Program before? Yes_______ No_________

Details: ____________________________________________________________________________

Have you ever taken an ExCET/TExES exam? Yes_____ No_____ TOPT/TOEFL Exam Scores__________________

What experiences do you have working with children in either a paid or volunteer position?
_____________________________________________________________________________________________

_____________________________________________________________________________________________

Have you worked as a substitute, teacher aide, or as a teacher on Emergency Permit?    Yes_____ No_____

   If yes, what district_____________________________________ Dates__________________________
Employment History
This section must be completed. A resume cannot be substituted. Starting with your most recent work
experience, list your employment history for the past five (5) years. Attach extra pages if necessary.
Employer_________________________ Date Started_____________ Date Left ____________

Supervisor’s Name____________________ Supervisor’s Title______ Phone __________________
Description of duties ______________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Reason for leaving ________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Employer_________________________ Date Started_____________ Date Left ___________
Supervisor’s Name____________________ Supervisor’s Title______ Phone __________________

Description of duties ______________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Reason for leaving ________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Employer _________________________ Date Started____________ Date Left ____________
Supervisor’s Name___________________ Supervisor’s Title ____________ Phone_____________
Description of duties ______________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Reason for leaving ________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Education

    Date Degree Granted         mm/dd/yyyy
      College/University
    City, State, Country
  Overall GPA(cumulative)
            Major
            Minor


    Date Degree Granted         mm/dd/yyyy
      College/University
    City, State, Country
  Overall GPA(cumulative)
            Major
            Minor
Proof of Proficiency
If you have taken the TASP and/or THEA, please indicate the date taken and your scores and provide
proof of proficiency.

Test _________________              Date Taken _____________

Reading Score _______________ Math Score ________________ Writing Score _____________________

Test ____________ Date Taken _____________

Reading Score _______________ Math Score ________________ Writing Score _____________________

Excused from TASP/THEA: Reason__________________________________________________________

References
Please provide South Texas Transition to Teaching-ACP with two personal references. Not immediate family
           Name                            Address                Phone Number           Relationship

_______________________________________________________________________________________

_______________________________________________________________________________________

Transcripts
Please provide our offices with a copy of an official university transcript or have an official college transcript
sent from any and or all colleges/universities you have attended.

Writing Sample
Write a one page essay to either one of the following questions.

1. Describe an experience you had in school (positive or negative) that has had a lasting effect on your life.

2. Why do I want to become a teacher?

								
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