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APPLICATION TYPE: SECONDARY POSITIONS

Thank you for you interest in Academica West. Please fill out the following application as completely as possible. The application is not saved or submitted until the “submit application” button has been pressed (at the end of the application), so be sure to collect all necessary information before beginning. Once you have submitted the application, you will receive a confirmation to the e-mail address entered here. Please e-mail us with questions.

Early Light Academy - South Jordan, UT Hawthorn Academy - West Jordan, UT Maria Montessori Academy - North Ogden, UT North Davis Preparatory Academy - Layton, UT North Star Academy - Bluffdale, UT Ogden Preparatory Academy - Ogden, UT Open High School of Utah - On-line school, SLC Office, UT Oquirrh Mountain Charter School - Kaysville, UT Quest Academy - West Haven, UT Syracuse Arts Academy - Syracuse, UT Wasatch Peak Academy - North Salt Lake, UT Academica West Registry - Northern UT Schools, UT Academica West Office - Kaysville, UT

CTE/Computer Literacy Secondary Fine Arts Secondary Foreign Language Secondary History Secondary Language Arts/English Secondary Mathematics Secondary PE/Health Secondary Science Secondary Spanish

Please enter comments or position preferences below:

PERSONAL INFORMATION

Name (first, last)	Email Address	Daytime Phone	Date of Availability
Current Street Address	City/State/Zip	Authorized to Work In

EDUCATION HISTORY

School/Program Location Degree/Level Major(s) Minor(s) GPA Dates

STUDENT TEACHING

Status:   completed     in process     other, please explain:

School Name

Location

School Type

Position

Grade Received

Dates

CERTIFICATION / LICENSURE

Issued By (state)	Certificate/License	Endorsements/Subjects	Expiration Date	Positions Qualified For
CACTUS ID (if applicable)		Are you highly qualified for the position you are applying for?   yes    no

WORK EXPERIENCE: EDUCATION

POSITION Location School Type (charter/public/private...) District/Division Name Contract Type Position(s) Description Dates

POSITION Location School Type (charter/public/private...) District/Division Name Contract Type Position(s) Description Dates

WORK EXPERIENCE: OTHER

Employer	Location	Position Title	Dates

MILITARY EXPERIENCE

Leave blank if not applicable.

Branch of Service

Duty Description

Dates

Type of Discharge

EXTRACURRICULAR ACTIVITIES

Activity	Description		Dates

LANGUAGE ABILITIES

Language	Abilities (check all that apply)
	Understand Conversationally    Speak Conversationally    Read    Write
	Understand Conversationally    Speak Conversationally    Read    Write
	Understand Conversationally    Speak Conversationally    Read    Write

AWARDS AND HONORS

Award/Honor	Description (if necessary)		Date (if necessary)

PROFESSIONAL MEMBERSHIPS

Organization	Office Held (if applicable) or Description (if necessary)		Dates

REFERENCES

Please add at least three references.

Name	Relationship	Position/Title	Company	Address	Phone	Email

BACKGROUND INFORMATION

Question	No	Yes	If yes, please explain
Have you ever been refused tenure, suspended, or terminated?
Have you ever been convicted of a crime or offense?
Have you ever had a teaching license revoked?
Have you ever been discharged or requested to resign a former position?
Have you undergone a criminal history record check within the last 90 days?

SUPPLEMENTAL QUESTIONS

Describe instructional methods used while teaching in the classroom.
What endorsements do you have, or are you working towards completing?
What extracurricular activities would you be interested in managing/helping to organize?
Please describe your philosophy of education.

COMMENTS

Enter additional comments about your application, if any:

SIGNATURE

I hereby certify that all statements made hereon are true and correct to the best of my knowledge and authorize Academica West representatives to investigate, either orally or in writing, any and all of my past and present work, education, and law enforcement records to ascertain any and all information which may be pertinent to my employment qualifications. The release of any and all information is authorized whether same is of record or not, and I do hereby release from all liability persons and organizations reporting information required by this application. I understand that any false statements or deliberate material omissions shall be sufficient cause for dismissal or disqualification from employment. I hereby waive any right to see any written materials submitted to the Management Company in response to the above inquiries or notes of any oral communication relative to such inquiries. I understand that if I am hired by the SCHOOL and any information received in response to the above inquiries is placed in my personnel file, that I may be denied the right to inspect such material. In the event I am employed by the SCHOOL, I also give my permission for the Director or their designee to provide on request from future prospective employers, any information relating to my employment with the SCHOOL.

In accordance with Utah State Law, applicant consents that SCHOOL may conduct a criminal background check, and I hereby waive my rights to written notice of such. No applicant for employment shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any educational program or activity on the basis of sex, race, religion, age, national origin or disability. Accommodations will be made as necessary for applicants with disabilities. In connection with my application for employment with SCHOOL, I hereby authorize the SCHOOL to investigate my past and present work, education, and law enforcement records to ascertain any and all information which may be pertinent to my qualifications. I do hereby release all persons, firms, agencies, companies, groups or installations from any damages of, or resulting from, providing such information. I further agree that a copy of this release shall function as an original.

I Agree    Signature:

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