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"*" indicates required fields

GENERAL INFORMATION

Name*
Address*
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*
Graduation Achieved #2

EMPLOYMENT HISTORY RELATED TO POSITION

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

FOR EDUCATOR POSITIONS ONLY

Do you currently possess a valid Pennsylvania Teaching Certification?
MM slash DD slash YYYY
Do you currently possess certifications from other states?
MM slash DD slash YYYY
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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