PDE - 353A (effective 3/1/99)

STANDARD APPLICATION

for Teaching Positions in

Pennsylvania Public Schools

(Please Type or Print)

POSITION(S) DESIRED

____________________________________________________________

Name

_____________________________________________________________________ ______

___

Last First Middle Social Security Number

Present Address _____________________________________________ (____)

_________________

Street Telephone

____________________________________________________________________________ ______

____

City State Zip

Permanent Address __________________________________________ (____)

_________________

Street Telephone

____________________________________________________________________________

City State Zip

E - mai l Address (if available) _____________________________________

List, in order of preference, the grades, subjects and/or positions for which you are applying:

1. ________________________ 2. _________________________ 3.

__________________________

CERT IFICATION (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.)

Area of Certification Issuing

State

Date

Issued

Have you acquired tenure in Pennsylvania? ________. If yes, in what school district? _______________

Federal Privacy Act [5 U.S.C. § 552a note] Statement. Authority for requesting social security account numbers

:, Public School Code of 1949 [24 P.S. § 12 -

1212, 24 P.S. § 1224] Principal Purpose: To verify certification. Other Purposes: Iden tification and collection of criminal/disciplinary records for certified

educators. Disclosure

: Mandatory. Failure to provide the SSAN will result in an applicant not being considered for employment.

PDE - 353A (effective 3/1/99)

_______________________________________________________________________________ _____________

Date available for employment ______________________________

If you are not employed full time, are you interested in being placed on our Substitute List? { Yes { No

Long - term { Yes { No Short - term { Yes { No

PDE - 353A (effective 3/1/99)

EDUCATIONAL B ACKGROUND

School or Institution and Location Major/Minor Diplomas,

Degrees or

Credits

Earned

Grade

Point

Average

(GPA)

High School

College/Universi

Graduate Study

EXPERIENCE (Present or most recent first)

Dates

From

___________

Name of Employer and Address

_____________________________________________

________

_____________________________________________

__________________Phone Number

____ ___________________________________

Your Title

_____________________________

______

Reason for Leaving

_____________________________

______

_____________________________

______

___________

Work Performed

_______________________________________ ____________________________________

_____________________________________________________________________________

_________________________________________________________________ ____________

__________________________________________

Name and Title

of Supervisor

Final Yearly Salary

Dates

From

___________

Name of Employer and Address

_____________________________________________

________

____________________________________ _________

_____________________________________________

__________________Phone Number

_______________________________________

Your Title

_____________________________

______

Reason for Leaving

_____________________________

______

_____________________________

______

___________

Work Performed

___________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________ ________________________

_____________________________________________________________________________ __________________________________________

Name and Title

of Supervisor

Final Yearly Salary

PDE - 353A (effective 3/1/99)

Dates

From

___________

Name of Employer and Addr ess

_____________________________________________

________

_____________________________________________

__________________Phone Number

_______________________________________

Your Title

__________________________ ____

______

Reason for Leaving

______________________________

______

______________________________

______

___________

Work Performed

____________________________________________________________________________

________________________________ _____________________________________________

_____________________________________________________________________________

_____________________________________________

Name and T itle

of Supervisor

Final Yearly Salary

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

____________________________________________________

_______________________________________________________________________________ ____________ _

__________________

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

STUDENT OR PRACTICE TEACHING

Grade or Subject Taught

Name and Address of School 1. College Supervisor

2. Cooperating Teacher

________ ___________________________

______

___________________________________

______

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 prin cipal 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.

Name Position Address Telephone

PDE - 353A (effective 3/1/99)

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:

_______________________________________________________________________________ _____________

___________________________________________________________ _________________________________

_______________________________________________________________________________ _____________

_______________________________________ _____________________________________________________

_______________________________________________________________________________ ___________

GENERAL BACKGROUND INFORMATION

You must give complete answers to all questions. If you answer “Yes” to any q uestion, 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 o n 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.

Were you ever convicted

of a criminal offense? { Yes { No

_____________ _________________________

_______

Are you currently under charges

for a criminal offense? { Yes { No

Have you ever forfeited bond

or collateral in connection

with a criminal offense?

{ Yes { No

Within the last ten years, have you been fired

from any job for any reason?

{ Yes { No

Within the last ten years, have you quit a job

after being notified that you would be fired?

{ Yes { No

Have you ever been professionally disciplined in any state? { Yes { No

P rofessionally disciplined means the annulment, revocation or suspension of your teaching

certification or having received a letter of reprimand from an agency, board or commission of

state government, such as the Pennsylvania Professional Standards and Pra ctices Commission.

Are you subject to any visa or immigration status which would prevent lawful employment?

{ Yes { No

_______________________________________________________________________________ ___

__________

PDE - 353A (effective 3/1/99)

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 nu mber.

ACT 34 COMPLIANCE (Background Check of Prospective Employees)

Each Pennsylvania resident must submit with his/her employment application a copy of a report of

Criminal History Record Information

from the Pennsylvania State Police or a statement f rom the

Pennsylvania State Police that the State Police Central Repository contains no such information relating to

that person. Each out - of - state applicant must submit with his/her application for employment a copy of a

federal criminal record history fr om the Federal Bureau of Investigation. The criminal record history

report must be no more than one (1) year old. The applicant MUST submit the ORIGINAL report prior to

employment.

************************************************************************* *******************

ACT 151 (PA Child Abuse History Clearance)

Each candidate must submit with his/her employment application a copy of an official clearance statement

obtained from the Pennsylvania Department of Public Welfare or a statement from the Dep artment of

Public Welfare that no record exists. The clearance statement must be no more than one (1) year old. The

applicant MUST

submit the ORIGINAL report prior to employment.

*************************************************************************** *****************

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.

********************** **********************************************************************

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 fait h. 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 a sk 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 med ical 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 unde r 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 concernin g allegations of

employment discrimination because of race, color, sex, religion, national origin, ancestry, age or disability.

__________________________________

_________________________________________

Date Signa ture 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, ance stry 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

PDE - 353A (effective 3/1/99)

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 (effective 3/1/99)

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 wa s developed, in accordance with Section 1204.1 of Act 107 of 1996, by the Pennsylvania Department of Education in consultation

with organizations representing school administrators, including personnel administrators, teachers and school boards. Question s should be referred

to PDE Bureau of Personnel at Voice Telephone (717) 787 - 4417, Text Telephone TTY (717) 783 - 8445 or FAX (717) 783 - 9348. If you need accommodation in

completing this application, including alternate format, please contact the school dis trict.