Form DoDEA Form 5010 DoDEA Form 5010 Department of Defense Dependents Schools (DoDDS) Applica

OMB No. 0704-0370
OMB approval expires

DEPARTMENT OF DEFENSE DEPENDENTS SCHOOLS (DoDDS)
APPLICATION FOR OVERSEAS EMPLOYMENT

The public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 1155 Defense
Pentagon, Washington, DC 20301-1155 (0704-0370). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with
a collection of information if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO:
DEPARTMENT OF DEFENSE DEPENDENTS SCHOOLS, HUMAN RESOURCES CENTER
4040 NORTH FAIRFAX DRIVE, ARLINGTON, VA 22203-1634
PRIVACY ACT STATEMENT
AUTHORITY: 20 USC Sections 902, 903, and E.O. 9397.
PRINCIPAL PURPOSE: Used to screen applicant for educational qualification and employment eligibility.
ROUTINE USE(S): Disclosures of germane information within the Department of Defense is authorized upon a demonstrated "need to know" to
perform official duty, including, but not limited to DoD attorneys rendering advice and assistance; DoD law enforcement or security activities for
investigative purposes. Routine disclosures of relevant and necessary information is authorized to agencies outside of the DoD by DoD Privacy Act
Systems Notices, which may be found at http://www.defenselink.mil/privacy/notices/osd/, including, but not limited to: (1) to the Office of Personnel
Management to verify or establish the selected applicant's pay and leave, benefits, retirement deduction, and for any other of OPM's legally authorized
government-wide personnel management functions and studies; (2) the appropriate Federal, State or local law enforcement agency in connection with
possible violation of law, whether civil, criminal or regulatory; (3) a Federal, State or local agency maintaining civil, criminal, relevant enforcement or
other pertinent information, such as current licenses, or to a Federal agency, concerning an investigation of an employee, the letting of a contract, or
the issuance of a license, grant or other benefit by the requesting agency, the hiring or retention of an employee or the issuance of a security
clearance; (4) in response to an inquiry from a Congressional office made at the request of the individual to whom the data in this form concerns; (5) to
the Office of Management and Budget in connection with the review of private relief legislation; (6) to foreign law enforcement, security, investigatory,
or administrative authorities in compliance with international agreements and arrangements; (7) to State and local taxing authorities for which an
employee or military member is or was subject to tax; (8) to any component of the Department of Justice for the purpose of representing the
Department of Defense, or any officer, employee or member of the Department in pending or potential litigation to which the record is pertinent; (9) to a
domestic or foreign entity for the purpose of counterintelligence activities authorized by U.S. Law or Executive Order or for the purpose of enforcing
laws which protect the national security of the United States; and (10) to the Merit Systems Protection Board, the General Services Administration, and
the National Archives and Records Administration for uses consistent with their respective statutory duties.
DISCLOSURE: Your disclosure of the information requested on this form is voluntary. However, your failure to disclose requested information may
delay or prevent your being considered for employment.
1. SOCIAL SECURITY NUMBER

2. BIRTH DATE (YYYYMMDD)

3. U.S. CITIZEN? (Must be a U.S. citizen)
YES

4. NAME (Last, First, Middle)

NO

5. E-MAIL ADDRESS

D R A F T

6. LOCAL ADDRESS (Street, Apartment Number, City, State, ZIP Code)

8. HOME TELEPHONE NUMBER
(Include Area Code)
11. AVAILABILITY DATE (YYYYMMDD)
a. SPOUSE'S NAME (Last, First, Middle)

7. PERMANENT ADDRESS (If different)

9. WORK TELEPHONE NUMBER
(Include Area Code)

12. IS SPOUSE APPLYING? (If Yes, complete a., b., and c., below)
YES
b. SSN

13. VETERAN PREFERENCE?

14a. HIGHEST DEGREE
HELD
NO PREFERENCE OR NOT A VETERAN

5-POINT
10-POINT
15a. ARE YOU A FORMER DoDDS TEACHER? b. LAST YEAR TAUGHT
YES (Complete b. - e.)
NO
e. NAME UNDER WHICH EMPLOYED
(If different from Item 4)

10. OTHER TELEPHONE NUMBER
(Include Area Code)

NO
c. CATEGORIES FOR WHICH SPOUSE IS APPLYING
b. MAJOR

c. NUMBER OF
YEARS

c. DEGREE GRANTED
(YYYYMMDD)
d. SCHOOL

16a. DO YOU HAVE A VALID STATE CERTIFICATE?
b. STATE
c. CATEGORIES

YES (Complete b. & c.)

NO

17. HAS A VALID STATE CERTIFICATE EVER BEEN REVOKED FOR CAUSE? (If Yes, explain)
YES
NO
18. HAVE YOU MET THE DoDEA PRAXIS REQUIREMENTS?
YES

NO

DoDEA FORM 5010, 20080505 DRAFT

19. TOTAL YEARS OF TEACHING EXPERIENCE IN FULL TIME,
PRE-K - 12, ACCREDITED SITUATION

PREVIOUS EDITION IS OBSOLETE.

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20. SUPERVISOR INFORMATION FOR UP TO 10 YEARS OF TEACHING EXPERIENCE IN PRE-K - 12 SITUATION
a. YOUR POSITION

c. TELEPHONE NUMBER
(Include Area Code)

b. SUPERVISOR NAME AND TITLE

21. HAVE YOU HAD TRAINING AND/OR EXPERIENCE IN THE FOLLOWING CURRICULA AND/OR INSTRUCTIONAL METHODS?
(X all that apply)
a. Language Immersion

u. Teaching Advanced Placement Courses

b. Business Lab

v. Peer Counseling

c. Early Childhood Education

w. Portfolio Assessment

d. Multiage/Multigrade Instruction

x. Water Safety Instruction

e. Conducting In-service Training

y. Human Sexuality

f. Drug and Alcohol Education

z. School to Work

g. English as a Second Language (ESL)

aa. Autism - Training or Experience

h. Service Learning

bb. Early Literacy

i. Cooperative Learning

cc. Centers Based Learning

j. School/Community Partnership

dd. Developmentally Appropriate Activities

k. Constructive Approach to Learning

ee. Experience with Different Level Abilities within the Same Classroom

l. Micro Based Labs

ff. Speaking and Understanding Foreign Language

m. NCTM Math Standards

gg. Guided Reading/Flexible Grouping

n. Reading Recovery

hh. Literature as Basis for Teaching Grammar, Usage and Mechanics

o. National Writing Project

ii.

Literature as Basis to Teach Phonics

p. Small School Experience

jj.

Standards-based Instruction

D R A F T

q. Resource Based Learning/Information

kk. Performance Assessment

r. Middle School Experience

ll.

s. Talented and Gifted

Technology as an Instructional Tool

mm. Involving Parents in the Education of Their Children

t. Distance Learning

nn. Other

22. EXTRA-CURRICULAR ACTIVITIES (If you have directed or coached activities listed below and are willing to do so, place an "X" in the
proper block(s).)
a. Athletic Director

g. Cross Country

m. Outward Bound

s. Track & Field

b. Swimming

h. Dramatics

n. Photography

t. Volleyball

c. Band/Orchestra

i. Football

o. School Publications

u. Wrestling

d. Baseball

j. Chorus

p. Soccer

v. Speech

e. Basketball

k. Golf

q. Softball

w. Debate

f. Cheerleader

l. Gymnastics

r. Tennis

x. JROTC Rifle Team

23. CERTIFICATION.

I certify that, to the best of my knowledge and belief, all of my statements are true, correct, complete, and made in good faith.
a. SIGNATURE (Sign in dark ink)

b. DATE SIGNED (YYYYMMDD)

24. FOR DoDEA USE ONLY

DoDEA FORM 5010 (BACK), 20080505 DRAFT

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