APPLICATION FORM CERTIFICATED EMPLOYMENT

							                                                              C amarillo A cademy of P rogressive E ducation
                                                                           777 Aileen Street, Camarillo, CA 93010
                                                                            (805) 384-1415 Fax:(805) 384-1473


                                                                        APPLICATION FORM
                                                                    CERTIFICATED EMPLOYMENT


NAME _______________________________________________________                         TODAY’S DATE _____________________________

ADDRESS ___________________________________________________                          HOME PHONE ______________________________

____________________________________________________________                         CELL/BUS. PHONE___________________________

   APPLICATION FOR:
      Level                                 Type of Service                                 Auxiliary Service

       _____ Kindergarten                   _____ Regular Teacher                           _____ Nurse

       _____ Elementary (1-5)               _____ Special Education Class                   _____ Other _____________________________

       _____ Intermediate (6-8)             _____ Administration


   Bilingual: No      Yes              Language(s) ________________________________________________________________________

   Grade or subject preference:

   1st Choice_______________________ 2nd Choice ______________________ 3rd Choice ____________________

   CALIFORNIA CREDENTIALS HELD                                 STANDARD:                                        RYAN:
                Credentials                              Major                            Minor                        Subject or Category




   Are your credentials recorded in the Ventura County Schools Office?                                □ Yes □ No

   EARNED ACADEMIC DEGREES FROM ACCREDITED COLLEGES AND UNIVERSITIES
       Degree         Date Granted                    Institution                           Major                             Minor




   Total number of semester units earned beyond B.A. __________                  Number beyond M.A. __________
   (1 quarter unit = 2/3 semester unit)

                              (NOTE: If employed, verification of salary placement by transcripts will be required.)
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STUDENT TEACHING
    Dates (From / To)                     Name of School                              Address                       Grade/Subject




TEACHING EXPERIENCE (List LAST position FIRST); indicate type: Regular, Substitute, Volunteer
    Dates (From / To)            Name of School                             Address                                 Grade/Subject




WORK EXPERIENCE OTHER THAN TEACHING
    Dates (From / To)        Name of Employer                                         Address                         Position(s)




U.S. MILITARY SERVICE: List service with dates of entrance, discharge, and rating or rank.

_________________________________________________________________________________________________________
(If elected, it will be necessary to furnish a photocopy of discharge.)

PLACEMENT FILE: My Placement papers are on file with the following placement office:

_________________________________________________________________________________________________________

Address __________________________________________________________________________________________________

Under the name of __________________________________________________________________________________________

PROFESSIONAL REFERENCES: (Limit your references to those people, other than those registered with a Placement Office, who
can best describe your competencies as they relate to the position for which you are applying. Indicate those that should NOT be
contacted at this time.

           Name                                 Position                          Mailing Address                   Phone Number




GENERAL INFORMATION

1.     Are you a U.S. Citizen?     Yes     No         If no, do you intend to become a U.S. citizen?   Yes    No

2.     Do you have any physical, mental, or medical impairment that would interfere with your ability to perform the job for which you
       are applying?     Yes     No       If yes, give details:

       ____________________________________________________________________________________________________




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3.     Have you been convicted of a misdemeanor that resulted in imprisonment, or are you currently out on bail pending trial for an
       arrest?  Yes No       If yes, please explain:
       ____________________________________________________________________________________________________

4.     Have you applied for a teaching position at C.A.P.E. previously?           Yes     No

5.     Have you ever taught at C.A.P.E. previously?          Yes      No        If yes, what position? ___________________________

6.     Is your spouse presently employed by C.A.P.E.?         Yes      No       If yes, what position? ___________________________

7.     Where are you now employed? __________________________________________________________________________
        Probationary   Permanent     Temporary    Reason(s) for leaving:
       ___________________________________________________________________________________________________

8.     Do you hold a contract for the next school year?       Yes      No

9.     When will you be free to contract for service at C.A.P.E.? _____________________________________________________

10.    Are you, or have you been a member of the California Teachers’ Retirement System (STRS)? Yes                No
       If yes, have you withdrawn your funds? Yes            No        What county? _______________________________________

11.    Can you teach in your classroom:           Art        Music         Spanish      Physical Education

12.    Do you play a musical instrument? Yes            No        If yes, please list _________________________________________

13.    Other special subjects you feel qualified to teach ____________________________________________________________

14.    List any extra-curricular activities with which you are willing/able to assist: (i.e. Speech, School Paper, Chorus, etc.)

       ___________________________________________________________________________________________________


Additional information may be provided by furnishing a resume.

(Note: A medical examination is required for first employment in a certificated position in California. The pre-employment medical
       exam shall be at the expense of the applicant.

IN AN EMERGENCY, PLEASE NOTIFY: ____________________________________________

Phone________________________________________________

Address _________________________________________________________________________________________________

READ CAREFULLY BEFORE SIGNING:

I hereby certify that all statements in this application are true, and I understand that any misstatement of material fact herein will cause
       forfeiture on my part of all rights to any employment with C.A.P.E.

SIGNATURE _____________________________________________                              DATE __________________________________

SOCIAL SECURITY NUMBER __________ ______ ____________

                                  AN EQUAL OPPORTUNITY CHARTER SCHOOL

NOTE: APPLICATION FORMS WILL BE KEPT ON FILE FOR THE LENGTH OF TIME REQUIRED BY LAW. APPLICANTS MUST
      RENEW APPLICATIONS BI-ANNUALLY PER CURRENT LAW.
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