act rgv application - ACT Houston - Alternative_9359

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act rgv application - ACT Houston - Alternative_9359

     APPLICATION Date of application: Pg 1/2

     Where are you applying? acthouston actdallas actaustin

    How did you hear about us? Online/Internet Friend/ISD/Personal Referral _______________________________ Job Fair Postcard Print name

     What would you like to teach? Grades EC-6 4-8 8-12 Subject(s)__________________________________


     Social Security #________-______- _______

     Complete Name: _______ ______ Maiden Name: ________________________

     last first mi

     Date of birth: / /____ U.S. citizen: Yes No Gender: M F Military Veteran: Yes No mm dd yyyy

     Ethnicity: Hispanic or Latino Not Hispanic or Latino Race: American Indian or Alaska Native Black or African American White Asian Hawaiian or other Pacific Islander Two or more races

     Mailing Address: ____________________________________________________________________________________________________ street Apt. # city state zip code Phone #s:

     Home: ________________________________ Cell: ____________________________ Work: ______________________________

    e-mail address: _______ ________

     TEACHING INFORMATION Are you now: Teaching Substitute teaching Working as para-professional or teacher aide ?

     If yes, list School/District ______________________________________________________________ How long? ________________

    Have you ever been accepted into another Alternative Certification Program? YES NO

     If yes, name of teacher preparation program(s) ___________________

     Name of TExES/ExCET exams taken: _________________________________________________________ Passed? YES NO

    Have you ever been issued a Texas Teaching Certificate? YES NO If yes, what kind? _____________________________

     List any permits or certificates held in other states or countries. (include subject, grade level, school district, state, dates)


     Provide the following information for all colleges, universities, junior or community colleges attended. Institution Dates Attended Degree Major/Minor





     Provide names, addresses and phone numbers for 3 personal character references not related to you.




     Pg 2/2


    In your own handwriting, describe what you as a person will bring to teaching. Explain how that will support your

     development as a teacher throughout your first year of teaching.


     Have you ever been convicted of a felony or subjected to a deferred adjudication on a felony charge? NO YES ;

     If your answer is “YES”, please explain on a separate sheet of paper.

     Note: Before hiring, school districts will conduct a criminal records check. A criminal record will jeopardize your eligibility for

     employment and participation in this program. A false statement on this application will disqualify you from admission.

     ACKNOWLEDGMENTS AND DISCLAIMERS I have answered all questions contained in this application truthfully to the best of my ability.

     I hereby give permission for this program to release the contents of my application to prospective employing

     school districts.

     I understand that the Application Fee is not refundable. The Preparation Program Institute Fee can be

     transferred to another Preparation Program Institute session, but will not be refunded after I have started the Institute.

     I understand that this alternative certification program reserves the right to make adjustments to requirements/program

     as required by changes made at the state level.

     I understand that I may not be accepted into the program if any of the following apply:

    1. Have prior unsuccessful attempts on any TExES/ExCET exams

    2. Have been unsuccessful in completing any other teacher preparation program

    3. Have been released, asked to resign, subject to contract non-renewal, or suspended for any reason for any

     period of time from employment by a school or school district.

     Signature Date

     Please schedule an appt. & bring completed application with official transcript(s) showing all coursework/grades/credits to:

     act;houston 9301 Southwest Freeway, Suite 250 Houston, TX 77074 Tel: 832-200-0552 FAX 832-200-0549

     act;dallas 1420 W. Mockingbird Lane, Suite 260 Dallas, TX 75247 Tel: 214-267-2222 FAX 214-267-2273

     act;austin Toll-free: 1-877-286-0024 (This location is a satellite of actdallas which maintains certification records.)

     No guarantee of certification is implied by acceptance into the program or completion of an internship /clinical teaching practicum. This application will be kept on file for a period of twelve months following the date of application.

     Thank you for your interest in becoming a certified teacher! March 2010

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