EmailMe Form - INSTRUCTOR APPLICATION

Instructor Position Being Applied For *

Name *

First Middle Last Suffix

UA Member Number *

Address *

Street Address City State / Province / Region Postal / Zip Code

Cell *

### - ### - ####

Email

Other

### - ### - ####

Date of Birth *

MM / DD / YYYY

Do you have legal right to work in the United States? *

YES

NO

If answered no to the above question, please explain:

List all skills in the areas you believe have a bearing on your qualifications for this position, such as: computers, equipment, additional training, certifications, company sponsored courses, teaching, etc. *

EDUCATION

Please provide the following information regarding your education.

Last elementary, junior or senior high school attended:
(please list name and location) *

Last school grade completed: *

Did you graduate? *

YES

NO

EMPLOYMENT HISTORY

Please list all employers, back to 5 years, starting with the most recent. If additional space is needed to list other positions, a supplemental sheet may be attached.

1) Name of Employer

Phone

### - ### - ####

Name and Title of Supervisor

Address (Include City, State & Zip Code)

Employed From

MM / YY

Position Title

To

MM / YY

Reason for Leaving

If current employer, write 'CURRENT'

Describe job responsibilities:

May present employer be contacted at this time? *

YES

NO

2) Name of Employer

Phone

### - ### - ####

Name and Title of Supervisor

Address (Include City, State & Zip Code)

Employed From

MM / YY

Position Title

To

MM / YY

Reason for Leaving

Describe job responsibilities:

3) Name of Employer

Phone

### - ### - ####

Name and Title of Supervisor

Address (Include City, State & Zip Code)

Employed From

MM / YY

Position Title

To

MM / YY

Reason for Leaving

Describe job responsibilities:

4) Name of Employer

Phone

### - ### - ####

Name and Title of Supervisor

Address (Include City, State & Zip Code)

Employed From

MM / YY

Position Title

To

MM / YY

Reason for Leaving

Describe job responsibilities:

Resume Upload (optional)

Additional Employer Upload (if needed)

REFERENCES

Please list a minimum of 3 references from persons qualified to evaluate your qualifications.

*

	Name	Occupation	Phone Number
Reference #1
Reference #2
Reference #3

TEACHING CERTIFICATE

All teaching positions require the instructor to obtain a teaching certificate from the school board which includes an extensive background check.

Signature of Applicant

Clear