Baxter Academy for Technology and Science Substitute Teacher Application

Baxter Academy for Technology and Science Substitute Teacher Application
**Baxter Academy does not discriminate in the operation of its education and employment policies, and will honor all appropriate laws related to discrimination**
Name*

First NameLast Name
Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Email*
example@example.com

EDUCATION:

	College/University Attended	Degree Awarded (if any)	# of Years Attended	G.P.A.
1
2
3
4

EXPERIENCE: Please list previous teaching/substituting experiences. Please attach a copy of your resume.

	Grade/Subject	Position	Employer	Dates (from/to)
1
2
3
4

REFERENCES: Please provide three references who are not related to you but who are familiar with your work as a teacher, substitute or who know of your experience working with youth.*

	Name	Relation	Phone #
1
2
3

Please indicate the day(s) you are available to substitute*

MondayTuesdayWednesdayThursdayFriday
Have you ever been disciplined, discharged, or asked to resign from a prior position?*

YesNo
Have you ever resigned from a prior position after a complaint had been received against you, or your conduct was under investigation or review?*

YesNo
Has your contract in prior position ever been non-renewed?*

YesNo
Have you ever been charged with or investigated for sexual abuse or harassment of another person?*

YesNo
Have you ever been convicted of a crime (other than a minor traffic offense)?*

YesNo
Have you ever entered a please of guilty or "no contest" to any crime (other than a minor traffic offense)?*

YesNo
Have you ever had a professional license or certificate suspended or revoked in any state or have you ever voluntarily surrendered, temporarily or permanently, a professional license or certificate in any state?*

YesNo
Has any court ever deferred, filed or dismissed proceedings without a finding of guilty and required that you pay a fine, penalty or court costs and/or imposed a requirement as to your behavior or conduct for a period of time in connection with any crime ( other than a minor traffic offense)?*

YesNo
If you have answered YES to any of the previous questions, provide full details below including, with respect to court actions, the date, offense in question, and the address of the court involved. Conviction or other disposition of a crime is not necessarily an automatic bar to employment.
Please Attach Any Supporting Document Here

Cancelof
SIGNATURE:

My signature below constitutes authorization to check my employment history, including without limitation, criminal arrest and conviction record checks, and reference checks.

I understand that information submitted in and with this application may be disclosed to a screening and/or interview committee, which may include board members, administrators, other staff, and members of the community. I give my consent to this disclosure.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: