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SIMI VALLEY ADULT SCHOOL & CAREER INSTITUTE Simi Valley Unified School District 1880 Blackstock Street Simi Valley, CA 93065 Application for Certificated Position Non-Management

NAME Present Address Street & No Permanent Address Street & No.

S.S. # City City State State Zip

Date Phone Phone Zip

Position(s) and school level(s) for which you are applying

(Check one or both) Regular Teaching California Credentials now held California Credentials you expect to receive & dates

Substitute Teaching

EDUCATIONAL AND PROFESSIONAL TRAINING - Begin with your most recent experience. Please convert quarter hours to semester hours (1 quarter hour = 2/3 semester hour). Attach additional sheet if necessary. Name of Location Dates Major Minor Semester Degree Institution From - To Hours

EXPERIENCE - List all employment experience, teaching and non-teaching, including student teaching and military experience. Begin with your most recent experience. Attach additional sheet if necessary. Position School District or Firm Location Dates From - To No. of Years

AN AFFIRMATIVE ACTION/EQUAL OPPORTUNITY EMPLOYER

Total Years of Teaching Experience (excluding Student Teaching) Are you now under contract? Have you filed an application with us before? Special Interests, Activities and Publications Date of expiration Date Position

SPECIAL INTERESTS, ACTIVITIES AND PUBLICATIONS Professional Organizations College/University Activities Community Activities Awards Publications

REFERENCES - List five references including three who know of your work professionally. Name Position City, State & Zip Code

Where are your confidential papers on file?

READ CAREFULLY BEFORE SIGNING I certify that the statements above are true and complete to the best of my knowledge. I understand that any misstatement or omission of fact will waive any rights to employment with the Simi Valley Unified School District. I waive the right to hold liable those persons whose names appear on this application form. __________________________________________________ SIGNATURE _________________________ DATE

Please return this completed form to:

SIMI VALLEY ADULT SCHOOL & CAREER INSTITUTE ATTN: Lynda Relyea 1880 Blackstock Street Simi Valley, CA 93065

Revised 6/13/06/pp

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SIMI VALLEY ADULT SCHOOL & CAREER INSTITUTE

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