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GENERAL INFORMATION

Name(Required)
Address(Required)
List all previous experiences involving youth (employment/volunteer):
Location/Address
Phone
Contact Person
Type of Work
Dates
 
Please type the position you are applying for:
Graduation Achieved #1(Required)
Graduation Achieved #2

EMPLOYMENT HISTORY RELATED TO POSITION

Workplace Address #1(Required)
May we contact this employer? (#1)(Required)
Workplace Address #2
May we contact this employer? (#2)
Have you ever been convicted of a felony?(Required)
Have you ever had your driver's license revoked or suspended?(Required)
Have you ever been convicted of child abuse or a crime involving actual or attempted sexual molestation of a minor?(Required)
Reference #1 - Name(Required)
Reference #1 - Address(Required)
Reference #2 - Name(Required)
Reference #2 - Address(Required)

FOR EDUCATOR POSITIONS ONLY

Do you currently possess a valid Pennsylvania Teaching Certification?
Do you currently possess certifications from other states?
Have you completed a state induction program?
Scholasitc Record
Type of School
School Name/Address
Dates Attended
Degree Earned
Date Degree Granted
 

SIGNATURE

This is for reference only and cannot be changed.
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