Ascension Parish Board Post Office Box 189 Donaldsonville, Louisiana 70346 CERTIFIED TEACHER APPLICATION FORM Date of Application PERSONAL INFORMATION PLEASE PRINT OR TYPE Date Available for Work (First) (Middle / Maiden) (Last) Social Security Number Mailing : Street City Permanent : Street City State Zip State Zip Home Phone Mobile Phone Email The following information is collected to complete Equal Opportunity reports required by law. While requested, you are not legally obligated to provide this information. Racial / Ethnic Group CERTIFICATION Do you hold a valid Louisiana teaching certificate? Yes No Type and Number Date Issued: List All Area(s) of Certification (as stated on certificate) Do you hold a valid certificate from another state? Yes No State & Number: Highly Qualified: Yes No List All Highly Qualified Areas Provide Documentation for HQ Status: Passed Content-Specific or Subject-Specific Exam National Board Certified Teacher Earned Master s Degree in Content Area Completed coursework equivalent to academic major in a content area Met the HOUSSE definition PRAXIS / NTE SCORES (Include a Copy of All Praxis / National Teacher Examination Scores) Praxis I Requirements PPST Reading (172) CBT Reading (319) Communication Skills (645) PPST Writing (171) CBT Writing (316) General Knowledge (644) PPST Math (170) CBT Math (315) Professional Knowledge (645) Praxis II Requirements Principles of Learning & Teaching: Grades K-6 (161) Grades 5-9 (154) Grades 7-12 (161) Content Knowledge / Specialty Area(s) and Score(s) (1) (2)
TEACHING EXPERIENCE (Begin with the most recent, exclude student teaching) Employed From To Employed From To Employed From To Employed From To TOTAL FULL-TIME TEACHING EXPERIENCE (IN YEARS) STUDENT TEACHING (Beginning, First Time Teachers Only) Dates Supervising Teacher University Supervisor
EDUCATION Bachelor's Degree: College or University Date of Graduation Grade Point Average Master s Degree: College or University Date of Graduation Grade Point Average Other Advanced Degree (s): College or University Degree Date of Graduation Grade Point Average REFERENCES (List at least three persons not related to you who know your ability as a teacher) Position Phone Position Phone Position Phone PREFERENCES / SKILLS / INTERESTS Level(s) for which you would Primary (grades K 4) Middle (grades 5 8) like to be considered: Secondary (grades 9 12) Special Education Other: Are you fluent in a foreign language? Yes No Specify: Are you interested in working in any of these areas? Art Yes No Club Sponsor Yes No Music Band / Choir Yes No Cheerleader Sponsor Yes No Coaching Boys Yes No Dance Team Sponsor Yes No Coaching Girls Yes No Yearbook / Newspaper Sponsor Yes No (Please feel free to provide additional information about your skills and interests on your resume.)
ADDITIONAL INFORMATION Military Service: Yes No Branch: Dates Teachers employed by the Ascension Parish Board are required to join the Teachers' Retirement System of Louisiana. Are you a member of the Teachers' Retirement System? Yes No Are you a retired teacher from the Teacher's Retirement System of Louisiana? Yes No If yes, did you retire after participating in the Deferred Retirement Option Plan (DROP)? Are you under contract now? Yes No Date of Expiration of System Have you ever been discharged or resigned in lieu of discharge from employment? Yes No Are you on approved leave from a school system? Yes No If yes, ending date: Have you ever been employed by Ascension Parish Board? Yes No If yes, when? Have you ever been convicted of any law violation outside of Louisiana (except a minor traffic violation)? Yes No If yes, explain: REQUIREMENTS This application will not be considered complete unless the following are included: 1. Copy of Louisiana Teaching Certificate If you have completed all requirements for a teaching certificate but have not yet received it, include documentation to this effect. If you do not have a Louisiana Teaching Certificate, you may contact the Division of Teacher Certification, Louisiana Department of Education, Post Office Box 94064, Baton Rouge, Louisiana 70804-9064, or phone 225-342-3490. 2. Copy of Praxis and/or National Teachers Examination scores (if applicable) 3. Official Transcript of college credits (No copies or scanned copies please) 4. Resume requested, but not required. In making this application for employment, it is understood that references and former employers may be contacted concerning job performance, and that information obtained will be confidential. In accordance with Board policy and state law, all applicants who are recommended for employment shall submit fingerprints for a criminal background check and undergo a drug screening. Applications are kept on file for one (1) year. R.S. 17:391.5H REQUIRES THAT ANY SCHOOL BOARD WISHING TO HIRE A PERSON WHO HAS BEEN EVALUATED PURSUANT TO ACT 506 WHETHER THAT PERSON IS ALREADY EMPLOYED BY THAT SCHOOL SYSTEM OR NOT, SHALL REQUEST SUCH PERSON'S EVALUATION RESULTS AS PART OF THE APPLICATION PROCESS. THE BOARD TO WHICH APPLICATION IS BEING MADE SHALL INFORM THE APPLICANT THAT AS PART OF THE MANDATED PROCESS, THE APPLICANT'S EVALUATION RESULTS WILL BE REQUESTED, THE APPLICANT SHALL BE GIVEN THE OPPORTUNITY TO APPLY, REVIEW THE INFORMATION RECEIVED, AND PROVIDE ANY RESPONSE OR INFORMATION THE APPLICANT DEEMS APPROPRIATE. AGREEMENT AND SIGNATURE I certify that the information in this application is true and correct without consequential omissions of any kind. I understand that furnishing false information or omitting information on this application could disqualify me for consideration for employment. You are hereby authorized to investigate my employment history. Signature: Date: Statement of Non-discrimination It is the policy of the Ascension Parish Board to provide equal opportunities without regard to race, color, national origin, sex, age, disabilities, or veteran status in its educational programs and activities. This includes, but not limited to, admissions, educational services, financial aid, and employment. Revised October 2006
Patrice Pujol Superintendent A.J. Nickens Board President District 5A Lorraine Wimberly Vice President District 6A P.O. Box 189 Donaldsonville, LA 70346 (225) 391-7000 (Gonzales) (225) 257-2000 (Donaldsonville) www.apsb.org Catherine Davis, District 1 Thomas Moose Pearce, District 2 Edgar Irvin, District 3 Kerry Diez, District 4A John Murphy, District 4B Taft Kleinpeter, District 5B Jamie Bourgeois, District 6B Troy Gautreau, Sr., District 7A Patricia Russo, District 7B Sexual Misconduct Disclosure Statement As required by R.S. 17:81.9 (Act 723), the applicant gives permission for all previous employers to disclose any information in the applicant's personnel file related to all instances of sexual misconduct with students committed by the applicant. The applicant releases previous and current employers from liability for providing the requested information to Ascension Parish Public s. Applicant cannot be considered for a position unless this form is signed. Once the form has been signed, the applicant may be hired on a conditional basis pending the board's review of any information obtained. Print Full Date Signature of Employee Social Security Number ---------------------------------------------------------------------------------------------------------------------------- This section to be completed by previous employer of System: Signature of Authorized HR Employee: There is no information in this employee s file indicating sexual misconduct. See attached documentation regarding sexual misconduct. ** A copy of this completed form is to be sent to all previous employing school boards and information should be returned within twenty (20) business days. ** Previous employer(s) should complete and return this form to: Ascension Parish Board Human Resources Department Post Office Box 189 Donaldsonville, Louisiana 70734 An Equal Opportunity Employer
Patrice Pujol Superintendent A.J. Nickens Board President District 5A Lorraine Wimberly Vice President District 6A P.O. Box 189 Donaldsonville, LA 70346 (225) 391-7000 (Gonzales) (225) 257-2000 (Donaldsonville) www.apsb.org EVALUATION REQUEST FORM Catherine Davis, District 1 Thomas Moose Pearce, District 2 Edgar Irvin, District 3 Kerry Diez, District 4A John Murphy, District 4B Taft Kleinpeter, District 5B Jamie Bourgeois, District 6B Troy Gautreau, Sr., District 7A Patricia Russo, District 7B TO: DATE: FROM: Human Resources Department We have received a teaching application from. We understand the above name is/was employed in your system. Please supply us with a copy of the last evaluation of this person in accordance with the guidelines in LA R.S. 17:3884. Concerning this evaluation: Was the job performance rated acceptable? Yes No Would you re-employ this applicant? Yes No If no, please explain. and title of person completing this request: System and : *Please remember to attach a copy of the applicant s last evaluation. I request the above school system release the requested information. Signature of Applicant Date Release of Evaluation Information LA.R.S. 17:3884 (D) requires that any school board wishing to hire a person who has been evaluated pursuant to the Children First Act, LA R.S. 17:3871, et seq., whether that person is already employed by that school system or not, shall request such person s evaluation results as part of the application process. Please be advised that, as part of the mandated process, your previous evaluation results will be requested. You have the opportunity to apply, review the information received, and provide and any response or information you deem appropriate. It is the policy of the Ascension Parish Board that no person in the school district shall, on the basis of age, race, color, creed, disability, religion, national origin, veteran status in its educational programs and activities, sex, or similar personal distinction be denied the benefits of, or be subject to discrimination in regard to employment, retention, promotion, transfer, or dismissal in any educational program or activity under the jurisdiction of the board. An Equal Opportunity Employer