California State University Channel Islands



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| |APPLICATION FORM - CERTIFICATED EMPLOYMENT 2012-2013 | |

*Please submit three Letters of recommendations with your application and a cover letter.

|Name | | |Date | | |

|Address | | |Home phone | | |

| | | |Business phone | | |

| | | |Cell phone | | |

| | |CALIFORNIA CREDENTIALS and SUBJECT AREA AUTHORIZATIONS NOW HELD | | | |

| | | |Subject Area / | | |

| |Credential | |Supplementary Authorization |Expiration Date | |

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| |Name of California | | | | |

| |Teaching Credential applied for: | |Date of Application: | | |

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| |Are your credentials recorded in the Ventura County Schools Office? |YES ______ NO ______ | | | |

| | |OUT OF STATE CREDENTIALS NOW HELD | | | |

| | | |Subject Area / |Issue Date / | |

| |State |Credential |Supplementary Authorization |Expiration Date | |

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| | |CBEST / CLAD / BILINGUAL (BCC or BCLAD) AUTHORIZATIONS | | | |

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| |Have you passed the CBEST? |YES ______ NO ______ |PENDING - Date Taken | | |

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| |Are you proficient in a language other than English? |YES ______ NO ______ |LANGUAGE | | |

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| |List BCC, BCLAD, LDS, ESL, CLAD, or SB1969 Credentials Held | | | | |

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| |List parts of Bilingual (BCC or BCLAD) Certificate exam you have passed | | | | |

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| | | |EARNED ACADEMIC DEGREES FROM ACCREDITED COLLEGES AND UNIVERSITIES | | | | |

| | | |List all Educational Institutes attended in order of attendance | | | | |

| |Location |Date |Date | | | | |

|Institution |City and State |From |To |Major |Minor |Degree |Date |

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| | | | |TOTAL Upper Division Semester Units earned AFTER Bachelor’s Degree? ________________ | | | |

| | | | |(1 Quarter Unit = 2/3 Semester Unit) | | | |

| | | |EXPERIENCE RECORD | | | |

| | | |List last position first. Indicate full time, part time, substitute, or student teaching. Report all paid teaching experience. | | | |

| | | |Account for each year since you began teaching. (Use separate sheet if necessary). | | | |

| |Month / Year | | | | | |

|FROM | | |School | |Grade / Subject | |

|TO | | |District | | | |

|FULL TIME | | |District Address | | | |

|PART TIME | | |District City/Zip | |Phone |( ) |

|SUBSTITUTE | | |Principal | |Phone |( ) |

| | | |Do you have a contract for next year? | | | |

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| |Month / Year | | | | | |

|FROM | | |School | |Grade / Subject | |

|TO | | |District | | | |

|FULL TIME | | |District Address | | | |

|PART TIME | | |District City/Zip | |Phone |( ) |

|SUBSTITUTE | | |Principal | |Phone |( ) |

| | | |Reason for Leaving | | | |

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| |Month / Year | | | | | |

|FROM | | |School | |Grade / Subject | |

|TO | | |District | | | |

|FULL TIME | | |District Address | | | |

|PART TIME | | |District City/Zip | |Phone |( ) |

|SUBSTITUTE | | |Principal | |Phone |( ) |

|STUDENT TCHNG | | |Reason for Leaving | | | |

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| |Month / Year | | | | | |

|FROM | | |School | |Grade / Subject | |

|TO | | |District | | | |

|FULL TIME | | |District Address | | | |

|PART TIME | | |District City/Zip | |Phone |( ) |

|SUBSTITUTE | | |Principal | |Phone |( ) |

|STUDENT TCHNG | | |Reason for Leaving | | | |

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| |Recent Trainings and /or Workshops related to curriculum development and instructional techniques. | | | |

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| |PROFESSIONAL REFERENCES | | | |

| |Include only those who have knowledge of your experience as an educator | | | |

| |(superintendents, principals, and supervisors.) | | | |

| |Name |Position |Phone & Mailing Address | |

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| |PERSONAL INFORMATION | | | | | |

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| |Have you ever been convicted of ANY misdemeanor or felony except: | | | | | |

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| |-Misdemeanor offense involving 28.5 grams or less of marijuana two or more years ago. |YES | |NO | | |

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| |Has your credential ever been suspended or revoked? |YES | |NO | | |

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| |Have you ever been dismissed or asked to resign from any teaching position? |YES | |NO | | |

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| |Have you ever left a teaching position prior to the expiration of a contract? |YES | |NO | | |

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| | | |NOTE |If you answered yes to any of the above, please attach a complete and accurate explanation of the circumstances to this | | |

| | | | |form. An answer of yes will not necessarily disqualify you from the position for which application is made, but any | | |

| | | | |failure to respond completely and accurately may result in your not being employed, or if discovered after employment, in | | |

| | | | |your dismissal. | | |

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| | | |SPECIAL INTERESTS YOU COULD SHARE WITH THE STAFF/STUDENTS | | | |

| | Music? | |Art? | |Drama? | |

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| |Physical Education? | |Dance? | |Other Special Activities? | |

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| |What Special training have you had in the following areas: | | | | | |

| | |Remedial Reading | | |Science | |

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| | |Special Education | | |Mathematics | |

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| | |Foreign Language | | |Technology | |

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|What do you do to keep current with new developments in instruction and/or in the content area in which you teach? |

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|Have you ever supervised a student teacher and/or an instructional aide? If yes, describe your successes & challenges in providing support to these individuals. |

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|What is your vision/experience with team collaboration? |

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|What contributions have you made to the teaching profession? (e.g. research, leadership roles, curriculum development, sharing and teaming with other teachers) |

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CERTIFICATION OF APPLICANT AND AUTHORIZATION TO RELEASE INFORMATION

I hereby certify that all statements made in this application are true and complete to the best of my knowledge, and authorize investigation of all statements herein recorded. I understand that any false statements or omissions of material facts may subject me to disqualification or dismissal if employed.

As an applicant for a position with the University Preparation School at CSUCI (UPS), I am required to furnish information and references for use in determining my qualifications. I understand that UPS may conduct an investigation of my work and/or personal history and that it may verify all data given in my application for employment, related papers, and/or oral interviews. I further understand that any and all of the references that I have provided to UPS, either in writing or otherwise, may be contacted. By signing this release form, I hereby authorize such investigation. In addition, I authorize any previous employer and/or any other references to release and fully disclose to any agent of UPS any information that such person may have concerning me, including information of a confidential or privileged nature, whether or not it is in their records.

I hereby release UPS, previous employers, and/or other references from any liability or damage that may result from furnishing the information requested.

A photocopy of this release form will be valid as an original thereof, even though the said photocopy does not contain my original signature.

Signature of Applicant: ______________________________________ Date: _______________

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University Preparation School

at CSU Channel Islands

University Charter Middle School

at CSU Channel Islands

550 Temple Avenue

Camarillo, CA 93010

(805) 482-4608

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