Teacher draft on-line application

APPENDIX C.4b
Draft Online Application

MTRP On-Line Application
PERSONAL INFORMATION
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is xxxx-xxxx. The time required to complete this information collection is estimated to average [30] minutes
per respondent, including the time to review instructions, gather the data needed, and complete and review the information collected. If you have any comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, DC 20202. If
you have comments or concerns regarding the status of your individual submission of this form, write directly to: U.S. Department of Education, Institute of
Education Sciences, 555 New Jersey Avenue, NW, Washington, DC 20208.

notice

First Name
Middle Name
Last Name
What is your former last name?
Social Security Number
Date of Birth

mm/dd/yyyy

Gender

Female; Male

Are you of Hispanic or Latino
origin?

Yes; No

What is your race?

American Indian or Alaskan Native; Asian; Black or African-American; Native Hawaiian or other Pacific Islander;
White

CONTACT INFORMATION
E-mail

E-mail

Current Address

Address
City
State/Province
Zip
Preferred Phone
Ext

Alternate Phone

BACKGROUND INFORMATION

General

General (cont.)

Did you attend an Information
Session?

Yes; No

At which [district] school do
you currently teach?
Which subject do you currently
teach?

Elementary; Language Arts; Mathematics

What grade do you currently
teach?

3rd; 4th; 5th; 6th; 7th; 8th

How many total years of fulltime, lead teaching
experience do you have?

1 - 40

How many years have you
been a full-time, lead teacher
in [district] schools?

1 - 40

Placement
Preferencs
Note: for actual
application,
geographical areas
names will be
specific to each site
and will not be
limited to 3 but will
include all possible
geographical areas.

We recognize that the [district] is large and some schools may be a great distance from where you live. Please indicate your
preference for each geographical area of the county, as follows:
1 = most highly preferred
2 = would consider position here
3 = would not, under any circumstances, consider a position here
Geographical area name 1
1, 2, or 3

Response
categories, planned

Sport 1

Geographical area name 2

1, 2, or 3

Geographical area name 3

1, 2, or 3

Please list any sports that you are interested in coaching. If you are not interested in coaching, please leave this section blank.
Answering this question will not affect the processing or consideration of your application in any way.
Baseball; Basketball; Bowling; Cheerleading; Cross County; Dance; Football; Golf;
Majorette; Soccer; Softball; Tennis; Track and Field; Volleyball

for a drop-down
menu format,
appear in
alphabetical order.

Sport 2

Baseball; Basketball; Bowling; Cheerleading; Cross County; Dance; Football; Golf;
Majorette; Soccer; Softball; Tennis; Track and Field; Volleyball

Sport 3

Baseball; Basketball; Bowling; Cheerleading; Cross County; Dance; Football; Golf;
Majorette; Soccer; Softball; Tennis; Track and Field; Volleyball

BACKGROUND INFORMATION (CONT.)

Please list any extracurricular activities you have led or are interested in leading. Answering this question will not affect the
processing or consideration of your application in any way.

Placement
Preferencs (cont.)

Language
Proficiency

Extra Curricular Activity 1

Art Club; Beta Club; Booster/Pep Club; Chess Club; Cinema, Drama, Theatre Club; Drama
Club; FBLA/BPA/Business/Marketing Club; Foreign Language Club; Future Farmers of
America; Future Teachers of America; International Club; JROTC Student Council; Key
Club; Knowledge Bowl/Trivia; Mock Trial/Debate/Speech Class; National Honor Society;
Newspaper; Other; Student Council; Yearbook

Extra Curricular Activity 2

Art Club; Beta Club; Booster/Pep Club; Chess Club; Cinema/Drama/ Theatre Club;
FBLA/BPA/Business/Marketing Club; Foreign Language Club; Future Farmers of America;
Future Teachers of America; International Club; JROTC Student Council; Key Club;
Knowledge Bowl/Trivia; Mock Trial/Debate/Speech Class; National Honor Society;
Newspaper; Other; Student Council; Yearbook

Extra Curricular Activity 3

Art Club; Beta Club; Booster/Pep Club; Chess Club; Cinema/Drama/Theatre Club;
FBLA/BPA/Business/Marketing Club; Foreign Language Club; Future Farmers of America;
Future Teachers of America; International Club; JROTC Student Council; Key Club;
Knowledge Bowl/Trivia; Mock Trial/Debate/Speech Class; National Honor Society;
Newspaper; Other; Student Council; Yearbook

Please indicate your level of proficiency in the following languages other than English.
Spanish

None; Basic Knowledge; Proficient; Fluent

Other

[specify language]; None; Basic Knowledge; Proficient; Fluent

What is your first language?

English; Spanish; Chinese; French; Other

CERTIFICATION
Please list up to three certifications you CURRENTLY POSSESS
State of Certification

Certification 1

Certification 2

Level

Early Childhood (PreK-3); Elementary (K-5); Middle School (6-8); High School (9-12); K-12

Endorsement Area

Art; Band/Orchestra; Bilingual; Biology; Chemistry; Computer Science; Early Childhood
(PreK-3); Elementary; English/Language Arts; ESL/ESOL; Family & Consumer Sciences;
Foreign Language; Health; History; Math; Media/Library Sciences; Music; Physical
Education; Physics; Science; Social Studies; Spanish; Speech; Technology

State of Certification

List of states and U.S. provinces

Level

Early Childhood (PreK-3); Elementary (K-5); Middle School (6-8); High School (9-12); K-12

Endorsement Area

Art; Band/Orchestra; Bilingual; Biology; Chemistry; Computer Science; Early Childhood
(PreK-3); Elementary; English/Language Arts; ESL/ESOL; Family & Consumer Sciences;
Foreign Language; Health; History; Math; Media/Library Sciences; Music; Physical
Education; Physics; Science; Social Studies; Spanish; Speech; Technology

State of Certification

Certification 3

Level

Early Childhood (PreK-3); Elementary (K-5); Middle School (6-8); High School (9-12); K-12

Endorsement Area

Art; Band/Orchestra; Bilingual; Biology; Chemistry; Computer Science; Early Childhood
(PreK-3); Elementary; English/Language Arts; ESL/ESOL; Family & Consumer Sciences;
Foreign Language; Health; History; Math; Media/Library Sciences; Music; Physical
Education; Physics; Science; Social Studies; Spanish; Speech; Technology

CERTIFICATION (cont.)

Please list up to three certification areas you will obtain by [date]
State of Certification

Certification 1

Level

Early Childhood (PreK-3); Elementary (K-5); High School (9-12); K-12; Middle School (6-8)

Endorsement Area

Art; Band/Orchestra; Bilingual; Biology; Chemistry; Computer Science; Early Childhood
(PreK-3); Elementary; English/Language Arts; ESL/ESOL; Family & Consumer Sciences;
Foreign Language; Health; History; Math; Media/Library Sciences; Music; Physical
Education; Physics; Science; Social Studies; Spanish; Speech; Technology

State of Certification

Certification 2

Level

Early Childhood (PreK-3); Elementary (K-5); High School (9-12); K-12; Middle School (6-8)

Endorsement Area

Art; Band/Orchestra; Bilingual; Biology; Chemistry; Computer Science; Early Childhood
(PreK-3); Elementary; English/Language Arts; ESL/ESOL; Family & Consumer Sciences;
Foreign Language; Health; History; Math; Media/Library Sciences; Music; Physical
Education; Physics; Science; Social Studies; Spanish; Speech; Technology

State of Certification

Certification 3

Level

Early Childhood (PreK-3); Elementary (K-5); High School (9-12); K-12; Middle School (6-8)

Endorsement Area

Art; Band/Orchestra; Bilingual; Biology; Chemistry; Computer Science; Early Childhood
(PreK-3); Elementary; English/Language Arts; ESL/ESOL; Family & Consumer Sciences;
Foreign Language; Health; History; Math; Media/Library Sciences; Music; Physical
Education; Physics; Science; Social Studies; Spanish; Speech; Technology

EDUCATION
Please include all colleges/universities and trade schools that you have attended. There are separate sections on this page for Primary
Undergraduate Degree, and Graduate-Level Degrees/Coursework.
What is your highest degree completed?

Bachelor’s; Bachelor’s + 15-29 credits; Master’s; Master’s + 15-29 credits; Master’s + 30-60
credits; Doctorate

PRIMARY UNDERGRADUATE DEGREE
Please enter information below for the accredited college/university from which you graduated and received your undergraduate degree.
Institution
City
State/Province
Country
Degree Type

Associate’s; B.A.; B.B.A.; B.E.; B.F.A.; B.M.; B.P.S.; B.S.; No Degree Received; NON-US;
Other

Other Degree
Major 1
If other, please specify
Major 2
If other; please specify
Minor
If other, please specify
GPA

4.0 to 1.0, inclusive; Not Calculated on 4.0 Scale; P/F Passed; P/F Failed

Degree received

mm/yyyy

GRADUATE-LEVEL DEGREES/COURSEWORK

Please enter information below for any Graduate or Doctorate-level degrees/coursework from accredited institutions. If there are more
than two Graduate or Doctorate-level institutions attended, please prioritize institutions from which you receive a degree over others.
Institution
City
State/Province
Country
Degree Type
Other Degree
Graduate 1

Major 1
If other, please specify
Major 2
If other; please specify
Minor
If other, please specify
GPA

4.0 to 1.0, inclusive; Not Calculated on 4.0 Scale; P/F Passed; P/F Failed

Degree
Received/Expected

mm/yyyy

GRADUATE-LEVEL DEGREES/COURSEWORK (cont.)

Institution
City
State/Province
Country
Degree Type
Other Degree
Graduate 2

Major 1
If other, please specify
Major 2
If other; please specify
Minor
If other, please specify
GPA

4.0 to 1.0, inclusive; Not Calculated on 4.0 Scale; P/F Passed; P/F Failed

Degree
Received/Expected

mm/yyyy

REFERENCES

Please provide at least one (and up to three) professional references. All should have firsthand knowledge of your professional
qualifications. By providing these references, candidates give direct permission to contact these individuals.
Name
Reference 1

Relationship
Organization
Telephone
Name

Reference 2

Relationship
Organization
Telephone
Name

Reference 3

Relationship
Organization
Telephone

RESUME AND APPLICATION QUESTIONS

Please attach your resume here.
Your resume must be in Microsoft Word 2006 (or earlier Word version) or PDF format. We cannot accept documents in Microsoft 2007, Microsoft
Works, etc.
1. Work history in chronological order – including dates of employment and descriptions of responsibilities and accomplishments.
2. Any previous achievements – academic, professional or personal.
3. Any community involvement or volunteer experience.
4. Any teaching, tutoring or other volunteer experience with children.
Please answer the following questions as they pertain to your application to transfer to a low-performing school in [district]. Please limit your
response to each question to 200 words or less.
What has made you a successful teacher?
How have your previous experiences and successes prepared you to excel in a low-performing school?