CONTACT INFORMATION
You must provide your email address and social security number.
First Name:
Middle Name:
Last Name:
Social Security Number:
Address:
City:
State:
Zip:
Telephone:		( )
Email Address:
Password:
Activity:		Active Inactive

PREFERENCES
List, in order of preference, the grades and/or subjects for which you would prefer to substitute teach:
First Choice:	Accounting 7-12Art K-12Biology 7-12Chemistry 7-12Communication 7-12Data Processing 7-12Early Childhood N-3Earth and Space Science 7-12Elementary K-6English 7-12French K-12General Science 7-12German K-12Health K-12Health and Physical Education K-12Hearing Impaired K-12Home Economics K-12Industrial Arts/Tech Ed K-12Library Science K-12Mathematics 7-12Mentally and/or Physically Handicapped K-12Music K-12Office Technologies 7-12Physics 7-12Reading Specialist K-12Social Studies 7-12Spanish K-12Speech and Language Impaired K-12Visually Impaired K-12Accounting 7-12Art K-12Biology 7-12Chemistry 7-12Communication 7-12Data Processing 7-12Early Childhood N-3Earth and Space Science 7-12Elementary K-6English 7-12French K-12General Science 7-12German K-12Health K-12Health and Physical Education K-12Hearing Impaired K-12Home Economics K-12Industrial Arts/Tech Ed K-12Library Science K-12Mathematics 7-12Mentally and/or Physically Handicapped K-12Music K-12Office Technologies 7-12Physics 7-12Reading Specialist K-12Social Studies 7-12Spanish K-12Speech and Language Impaired K-12Visually Impaired K-12
Second Choice:	Accounting 7-12Art K-12Biology 7-12Chemistry 7-12Communication 7-12Data Processing 7-12Early Childhood N-3Earth and Space Science 7-12Elementary K-6English 7-12French K-12General Science 7-12German K-12Health K-12Health and Physical Education K-12Hearing Impaired K-12Home Economics K-12Industrial Arts/Tech Ed K-12Library Science K-12Mathematics 7-12Mentally and/or Physically Handicapped K-12Music K-12Office Technologies 7-12Physics 7-12Reading Specialist K-12Social Studies 7-12Spanish K-12Speech and Language Impaired K-12Visually Impaired K-12Accounting 7-12Art K-12Biology 7-12Chemistry 7-12Communication 7-12Data Processing 7-12Early Childhood N-3Earth and Space Science 7-12Elementary K-6English 7-12French K-12General Science 7-12German K-12Health K-12Health and Physical Education K-12Hearing Impaired K-12Home Economics K-12Industrial Arts/Tech Ed K-12Library Science K-12Mathematics 7-12Mentally and/or Physically Handicapped K-12Music K-12Office Technologies 7-12Physics 7-12Reading Specialist K-12Social Studies 7-12Spanish K-12Speech and Language Impaired K-12Visually Impaired K-12
Third Choice:	Accounting 7-12Art K-12Biology 7-12Chemistry 7-12Communication 7-12Data Processing 7-12Early Childhood N-3Earth and Space Science 7-12Elementary K-6English 7-12French K-12General Science 7-12German K-12Health K-12Health and Physical Education K-12Hearing Impaired K-12Home Economics K-12Industrial Arts/Tech Ed K-12Library Science K-12Mathematics 7-12Mentally and/or Physically Handicapped K-12Music K-12Office Technologies 7-12Physics 7-12Reading Specialist K-12Social Studies 7-12Spanish K-12Speech and Language Impaired K-12Visually Impaired K-12Accounting 7-12Art K-12Biology 7-12Chemistry 7-12Communication 7-12Data Processing 7-12Early Childhood N-3Earth and Space Science 7-12Elementary K-6English 7-12French K-12General Science 7-12German K-12Health K-12Health and Physical Education K-12Hearing Impaired K-12Home Economics K-12Industrial Arts/Tech Ed K-12Library Science K-12Mathematics 7-12Mentally and/or Physically Handicapped K-12Music K-12Office Technologies 7-12Physics 7-12Reading Specialist K-12Social Studies 7-12Spanish K-12Speech and Language Impaired K-12Visually Impaired K-12

AVAILABILITY
Please specify the date that you are available for employment and the days of the week that you are available to work.
Date Available: (8/1/01 format)
Weekdays Available:	MondayTuesdayWednesdayThursdayFridayAnyMondayTuesdayWednesdayThursdayFridayAny

SCHOOL DISTRICT PREFERENCE
Please indicate your preference for employment in the different school districts.
School Districts:	Sto-Rox School DistrictMoon Area School DistrictEast Allegheny School District
Code

EDUCATIONAL BACKGROUND
HighSchool
School or Institution and Location:
Major/Minor:
Diplomas, Degrees or Credits Earned
Grade Point Average:

HighSchool
School or Institution and Location:
Major/Minor:
Diplomas, Degrees or Credits Earned
Grade Point Average:

College/University
School or Institution and Location:
Major/Minor:
Diplomas, Degrees or Credits Earned
Grade Point Average:

College/University
School or Institution and Location:
Major/Minor:
Diplomas, Degrees or Credits Earned
Grade Point Average:

Graduate Study
School or Institution and Location:
Major/Minor:
Diplomas, Degrees or Credits Earned
Grade Point Average:

Graduate Study
School or Institution and Location:
Major/Minor:
Diplomas, Degrees or Credits Earned
Grade Point Average:

EMPLOYMENT EXPERIENCE
Date:		FROM TO
Name of Employer and Address:
Phone Number:
Work Performed:
Your Title:
Reason for Leaving:
Name and Title of Supervisor:
Final Yearly Salary:
Work Performed:

Date:		FROM TO
Name of Employer and Address:
Phone Number:
Work Performed:
Your Title:
Reason for Leaving:
Name and Title of Supervisor:
Final Yearly Salary:
Work Performed:

Date:		FROM TO
Name of Employer and Address:
Phone Number:
Work Performed:
Your Title:
Reason for Leaving:
Name and Title of Supervisor:
Final Yearly Salary:
Work Performed:

EXPERIENCE WORKING WITH CHILDREN
Age Group
Name and Address Experience
Contact Name

Age Group
Name and Address Experience
Contact Name

Age Group
Name and Address Experience
Contact Name

REFERENCES
References should include one personal reference, two professional references (managers and/or professors) and at least one person who has first hand knowledge of your experience working with children.
Name
Position
Address
Telephone

Name
Position
Address
Telephone

Name
Position
Address
Telephone

OTHER QUALIFICATIONS

Summarize special job-related skills and qualifications acquired from employment or other experiences (including U.S. military service) and/or state any additional information you feel may be helpful in considering your application, i.e. honors, awards, activities, technology, skills or professional development activities.

There is a 500 character limit in this field.

Please list activities that you are qualified to supervise or coach.

There is a 500 character limit in this field.

GENERAL BACKGROUND INFORMATON
You must give complete answers to all questions. If you answer "Yes" to any questions, you must list all offenses, and for each conviction provide date of conviction and disposition, regardless of the date or location of occurance. Conviction of a criminal offense is not a bar to employment in all cases. Each case is considered on its merits. Your answers will be verified with appropriate police records. Criminal offense includes felonies, misdemeanors, summary offenses and convictions resulting from a plea of "nolo contendere" (no contest). Conviction is an adjunction of guilt and includes determinations before a court, a district justice or a magistrate which results in a fine, sentence or probation. You may omit: minor traffic, offenses committed before your 18th birthday which were adjudicated in juvenile court or under a Youth Offender Law, and any convictions which have been expunged by a court or for which you successfully completed an Accelerated Rehabilitative Disposition program.
Were you ever convicted of a criminal offense?		YES NO
Are you currently under charges for a criminal offense?		YES NO
Have you ever forfeited bond or collateral in connection with a criminal offense?		YES NO
Withing the last ten years, have you been fired from any job for any reason?		YES NO
Within the last ten years, have you quit a job after being notified that you would be fired?		YES NO
Are you subject to any visa or immigration status which would prevent lawful employment?		YES NO
Note: If you answered "Yes" to any of the above questions, please provide a detailed explanation on a separate sheet of paper, including dates, and attach it to this application. Please print and sign your name on the sheet, and include your social security number.

ACT 34 COMPLIANCE

Background Check of Prospective Employees

Each Pennsylvania resident must submit with his/her employment application a copy of a report of Criminal History Record Information from the Pennsylvania State Police or a statement from the Pennsylvania State Police that the State police Central Repository contains no such information relating to that person. Each out-of-state applicant must submit with his/her application for employment a copy of a federal criminal record history from the Federal Bureau of Investigation. The criminal record history report must be no more than one (1) year old. The applicant MUST submit the ORIGINAL report prior to employment.

ACT 151

PA Child Abuse History Clearance

Each candidate must submit with his/her employment application a copy of an official clearance statement obtained from the Pennsylvania Department of Public Welfare or a statement from the Department of Public Welfare that no record exisits. The clearance statement must be no more than one (1) year old. The applicant MUST submit the ORIGINAL report prior to employment.

ESSAY

Please write an essay describing your reasons for wanting to participate in the Smart START Program. You may attach an additional sheet of paper to your application. Please print and sign your name at the bottom of the essay.

CERTIFICATION AND RELEASE AUTHORIZATION

I certify that all the statements made by me are true, complete and correct to the best of my knowledge and belief, and are made in good faith. I further certify that I am the sole author of the essay. I understand that any misrepresentation of information shall be sufficient cause for: (1) rejecting my candidacy, (2) withdrawing of any offer of employment, or (3) terminating my employment.

I hereby authorize any and all of my previous employers and/or supervisors to release any and all of my personnel records, and to respond fully and completely to all questions that officals of The Allegheny Intermediate Unit mau ask regarding my prior work history and performance. I will hold such previous employers and/or supervisors harmless of any and all claims that I might otherwise have against them with regard to statements made to this school district. I further authorize these officials to investigate my background, now or in the future, to verify the information provided and release from liability all persons and/or entities supplying information regarding my background. However, I do not authorize the production of medical records or other information which would tend to actually identify a disability nor do I authorize inquiries which would include information related to any medical condition or medical history. Further, I do not waive any rights which I may have under state or federal law related to my right to challenge the disclosure of unlawful or inaccurate information, whether by the school district or by entities or persons providing such information to the school district, including any and all claims concerning allegations of employment discrimination because of race, color, sex, religion, national origin, ancestry, age or disability.

It is the policy of the Allegheny Intermediate Unit Board not to discriminate on the basis of race, sex, religious creed, color, sexual orientation, national origin, ancestry, age, disability, or limited English proficiency, in its educational programs, services, facilities, activities, or employment policies as required by Title IX of the 1972 Educational Amendments, Title VI and VII of the Civil Rights Act of 1964 as amended, Section 504 Regulations of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, Section 204 Regulations of the 1984 Carl D. Perkins Act, the Americans with Disabilities Act, or any other applicable federal and state statutes.  An open and equitable personnel system will be established and maintained.   Employment opportunities shall be provided for applicants with disabilities and reasonable accommodation(s) shall be made to meet the physical or mental limitations of qualified applicants or employees.