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Instructors Application Form
CJCPCS IS AN EQUAL OPPORTUNITY EMPLOYER
Your e-mail address:
Your name:*
Position applying for:*
APPLICANT'S ADDRESS INFORMATION
APPLICANT'S PERSONAL INFORMATION
EDUCATION AND PROFESSIONAL PREPARATION
CERTIFICATION
(You must include a copy of your certification)
LastName:*
FirstName:*
Middle Name:
Date of Birth(M/D/Y):*
Gender:*
Address:*
City:*
Zip Code:*
Home Phone No:*
Work Address:
Present Employer:
Title:
Current Salary:
Graduate Institution:
Address:
Degree:
Total Semester Credit Hours:
Major Subject / Semester Credit Hours:
Minor Subject/Semester Credit Hours:
High School:
Address:
Type of Program:
Area of Certification:
Date(s) Issued:
Type:
University Placement Credentials on file at:
EMPLOYMENT HISTORY
(Include student teaching if it is your most recent experience.)
SURVEY
How did you learn about us:
Briefly state why you wish to have your child/children enrolled at NjCollegePREP:
I/We hereby certify that, to the best of my/our knowledge and belief, the answers to the foregoing questions and statements made by me/us in this application are complete and accurate. I/We understand that any false information, omissions, or misrepresentations of facts may result in rejection of this application or future dismissal of the applicant.
Graduate Institution:
Address:
Degree:
Total Semester Credit Hours:
Major Subject / Semester Credit Hours:
Minor Subject/Semester Credit Hours:
Undergraduate Institution:
Address:
Degree:
Total Semester Credit Hours:
Major Subject / Semester Credit Hours:
Minor Subject/Semester Credit Hours:
School:
Location:
Grade or Subject:
Lenght of Service:
School:
Location:
Grade or Subject:
Lenght of Service:
School:
Location:
Grade or Subject:
Lenght of Service:
OTHER
(Include student teaching if it is your most recent experience.)
Academic Awards or Honors:
Professional Memberships:
Professional Subscriptions:
Professional Training or Workshops Conducted or Attended:
Professional Writing Published:
Are you a United States Citizen?
Have you ever been convicted of a crime?
Have you ever been dismissed or asked to resign from any position or job?
If you answered "yes" to either of the last two questions, please provide an explanation below.
REFERENCES
Please provide three references who are familiar with your work history. You may list superintendents, principals, and supervisors under whom you have taught or worked, and others who may have firsthand knowledge of your abilities, skills, knowledge, and character as a teacher or administrator.
Name:
Title:
Address:
City:
State, Zip:
Phone:
Name:
Title:
Address:
City:
State, Zip:
Phone:
Name:
Title:
Address:
City:
State, Zip:
Phone:
I hereby authorize any individual, company, or institution listed above with whom I have been associated to furnish the NjCollegePREP with any information concerning my employment.
Name:
Date:
All application materials will be kept on file for one year from date of receipt.
NjCollegePREP is in compliance with the Educational Amendments of 1972; Title IX specifically disallowing any practice of discrimination.
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