MOFFAT COUNTY SCHOOL DISTRICT RE-1	                                                                                  FOR OFFICE USE ONLY:
775 YAMPA AVENUE							                              ______ Interview (initial & date)
CRAIG, COLORADO 81625						                                 ______ References ck'd (initial &date)
TELEPHONE and FAX (970-824-6655)


APPLICATION FOR LICENSED PERSONNEL

Name: 	 
		Last				                        First			 		 Middle

Other names under which records may be found:	

Social Security Number: _______________________ FAX: _______________________ E-Mail: 	

Present Address: 	
		     Street			City			State		Zip Code		Telephone

Permanent Address: 	
		     Street			City			State		Zip Code		Telephone


POSITION DESIRED:  __________________________________________________

Indicate your top		  _______ Primary (K-2)		  _____ Intermediate (5-6)                   _____ High School (9-12)
two / three
preferences in the		  _______ Upper Elementary (3-4)     _____ Middle School (7-8))  
order in which
you wish to teach.
				


List below in order of preference the subject (secondary) or grade levels (elementary), or specialist field for which you are qualified to teach.
SUBJECT / GRADE AREAS                                                                               SEMESTER HOURS

1. __________________________________________________________________________                   
2. __________________________________________________________________________                   
3. __________________________________________________________________________ 
 

Do you hold a valid Colorado Teaching License?   Yes ________   No _______    Attach Copy ________

Number ________ Type ______________________________ Endorsement _____________________________ Exp. Date _______

Are you presently under contract?   Yes ____________ No _____________ Date Available _________________________________

ATTACH RESUME OR COMPLETE THE FOLLOWING                                                    Resume attached: ____Yes ____ No 

PROFESSIONAL PREPARATION


COLLEGE AND UNIVERSITY WORK RESULTING IN A DEGREE

Name of Institution		Major		Hrs.	    Minor	Hrs.		Year Graduated		Degree

1. __________________________________________________________________________________________________________

2. __________________________________________________________________________________________________________

3. __________________________________________________________________________________________________________

4. __________________________________________________________________________________________________________

SPECIAL TRAINING OR SKILLS NOT INCLUDED IN DEGREE WORK ABOVE

Name of Institution		Year Attended		Subjects		  Credit Earned	    _____Time in Years

1. __________________________________________________________________________________________________________

2. __________________________________________________________________________________________________________

3. __________________________________________________________________________________________________________

PROFESSIONAL EXPERIENCE

STUDENT TEACHING EXPERIENCE

From: ______ / ______ to: ______ /  ______ Grade and/or Subject  _____________________________________________________
            Mo.             Yr.              Mo.             Yr.

School: _____________________________________ Location: ______________         _____________          __________________
      			Name				             City		      State	                         Phone number

Name of Cooperating Teacher: __________________________________________________________________________________

TEACHING EXPERIENCE

  
         Years taught   		     Name of School		Grades and/	
____ ____			     City and State		 or Subject	  __                        Supervisor__________

1. ________________________________________________________________________________________________________

2. ________________________________________________________________________________________________________

3. ________________________________________________________________________________________________________

4. ________________________________________________________________________________________________________

REFERENCES


Name				Address	                                  Phone                                       Position

1. ________________________________________________________________________________________________________
2. ________________________________________________________________________________________________________
3. ________________________________________________________________________________________________________

QUESTIONS



1. The state of Colorado has adopted content standards.  How would you incorporate these into your instruction? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
2. In your classroom, how will you know students are learning, and what will you do when some are not? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
               ____________________________________________________________________________________________________
3. Classrooms have students of different abilities.  What strategies will you utilize to accommodate all students in the learning process? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
4. Moffat County Schools have a philosophy of working in collaborative teams to meet student achievement goals.  List advantages of this method of operation and describe your ability to function as a team member. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
5. What are the roles and responsibilities of parents and students in the learning process? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


SUPPLEMENTARY INFORMATION


List specific training you have taken in

* Reading: ____________________________________________________________________________________________    ____________________________________________________________________________________________________
* Writing: ________________________________________________________________________________________________________________________________________________________________________________________________________                                
* Math: ________________________________________________________________________________________________________________________________________________________________________________________________________
* ESL: ________________________________________________________________________________________________________________________________________________________________________________________________________
* Technology: ________________________________________________________________________________________________________________________________________________________________________________________________________
 

List activities you feel competent to direct:
                             ACTIVITY                                                                EXPERIENCE
1. ____________________________________________________________________________________________________
2. ____________________________________________________________________________________________________
3. ____________________________________________________________________________________________________

Other skills, experiences, or comments: ___________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________


Please explain by confidential letter if you answer yes to any of the following:

Have you ever had a teaching license revoked?      			Yes _____	No _____
Have you ever been convicted of a felony?				Yes _____	No _____
Are you involved in any pending litigation?				Yes _____	No _____

I understand any false statements or misrepresentation of facts on this application are grounds for dismissal.  I hereby certify that the statements above are true and correct to the best of my knowledge and belief.

								__________________________________________________

Signature of Applicant


Moffat County School District does not discriminate on the basis of race, color, national origin, sex or handicap.  Compliance officers for Title IX: Mr. Pete Bergmann, and 504: Dr. Christine Villard.