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

CUI (When Filled In)

DEPARTMENT OF DEFENSE EDUCATION ACTIVITY (DoDEA)
APPLICATION FOR OVERSEAS EMPLOYMENT

OMB No.: 0704-0370
OMB approval expires:

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, 4800 Mark Center
Drive, Alexandria, VA 22350-3100 (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:
Civilian Human Resources Agency (CHRA)
DoDEA Recruitment Cell, North Central Region
ATTN: CHRA-NCR-K
1 Rock Island Arsenal, Building 104, Rock Island, IL 61299-7650

PRIVACY ACT STATEMENT
AUTHORITY: 20 U.S.C. Sections 902, 903, and 921-932; and E.O. 9397 SSN, as amended.
PRINCIPAL PURPOSE: Information is collected from applicants to determine educational qualification, employment eligibility, and employment
verification. Information is covered by OPM/GOVT-5, "Recruiting Examining and Placement Records," https://www.opm.gov/informationmanagement/privacy-policy/sorn/opm-sorn-govt-5-recruiting-examining-and-placement-records.pdf. Upon entry into Federal service the form is
maintained under OPM/GOVT-1, "General Personnel Records," https://www.opm.gov/information-management/privacy-policy/sorn/opm-sorngovt-1-general-personnel-records.pdf.
ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended, the
information may be disclosed outside the DoD pursuant to 5 U.S.C. 552a(b)(3). To disclose to appropriate Federal officials pertinent workforce
information for use in national or homeland security emergency/disaster response. Additional routine uses are listed in the applicable System of
Records Notice: OPM/GOVT-1, General Personnel Records at: https://www.opm.gov/information-management/privacy-policy/sorn/opm-sorngovt-1-general-personnel-records.pdf.
DISCLOSURE: Voluntary; however, failure to provide the requested information may delay or prevent the processing of an application for a
teaching position.
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)

7. PERMANENT ADDRESS (If different)

9. WORK TELEPHONE NUMBER
(Include Area Code)

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

NO
b. CATEGORIES FOR WHICH SPOUSE IS APPLYING

a. SPOUSE'S NAME (Last, First, Middle)
13. VETERAN PREFERENCE?
NO PREFERENCE OR NOT A VETERAN

14a. HIGHEST DEGREE
HELD

5-POINT
10-POINT
15a. ARE YOU A FORMER DoDEA 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)

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, MONTH YEAR

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

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CUI (When Filled In)
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

D R A F T
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

q. Resource Based Learning/Information

kk. Performance Assessment

r. Middle School Experience

ll.

s. Talented and Gifted

mm. Involving Parents in the Education of Their Children

t. Distance Learning

nn. Other

Technology as an Instructional Tool

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.
b. DATE SIGNED (YYYYMMDD)

a. SIGNATURE (Sign in dark ink)

24. FOR DoDEA USE ONLY

DoDEA Form 5010 (BACK), MONTH YEAR

Controlled By: DoDEA
Category: PERS
LDC: CHRA
POC: HR Policy & Compliance Branch

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