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Last Name:
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Address:
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City:
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State:
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Zip Code:
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Home Telephone Number:
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Alternate Telephone:
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E-Mail Address:
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Social Security Number:
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Gender
(for statistical
purposes only):
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Date of Birth:
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(Example 6/01/2008) |
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Race
(for statistical purposes only):
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Check here if you will NOT be a resident of Tennessee while taking
classes online. |
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Part II Program Section |
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Please check one: |
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Please indicate your degree(s), major and
University:
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Grade Point Average (GPA), Minimum (GPA)
2.5:
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In what school district are you currently
teaching or have been issued a contract? SEE ATTACHED LIST for eligible TN.
school systems:
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School system:
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School:
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Principal:
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Please provide a copy of your signed
contract or a letter from the school district verifying employment. |
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Letter/contact is attached: |
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Part III |
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Have you ever
been convicted of any offenses involving the sexual molestation, physical
or sexual abuse or rape of a child? |
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If YES,
explain in detail on the back of the application. |
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Have you ever
been the subject of a founded case of child abuse and neglect? |
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If YES, explain
in detail on the back of the application. |
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Have you ever
plead guilty or been convicted of a violation of law (either civilian or
military) other than minor traffic violations? |
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If YES, give
dates, places, charges & disposition on the back of the application. |
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Have you ever
been refused renewal of contract? If YES, explain in detail on the
back of the application. |
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Part IV Education |
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Name of Institution |
Location (City/State) |
Dates Attended |
Degree (if earned) |
Major/Minor
Subjects |
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Part V Work Experience
(List chronologically, beginning with the most recent) |
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Employer |
Address |
Kind of Work |
Dates of
Employment |
Reason for
Leaving |
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Part VI Reference |
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Employer/Supervisor |
Dates |
Address |
Phone |
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Personal References |
Relationship
(may not include family) |
Address |
Phone |
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Part VII PROGRAM PREREQUISITE, please attach a copy of your
PRAXIS II scores. |
* You Must Pass the PRAXIS II Content Exam That Corresponds
To Your Degree and the License
You Are Seeking (visit
www.ets.org/praxis for
registration information). |
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If you have not taken the PRAXIS II test(s), please indicate
the date you are scheduled to
take the test(s) and include confirmation of registration. |
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PART IX – PERSONAL STATEMENT (Please provide a written statement as to your
desire to teach in a high need Tennessee middle or high school.) Include
examples and past experiences that have helped you make this decision. This
section will be used to aid in selection of individuals for interview. You
may attach a typed page if you wish. |
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