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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)__________________________________

     PERSONAL INFORMATION

     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)

     _ EDUCATIONAL BACKGROUND

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

     _____

     _____

     _____

     CHARACTER REFERENCES

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

    1.

    2.

    3.

     Pg 2/2

     PERSONAL POINT-OF-VIEW

    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.

     DISCLOSURE OF LEGAL HISTORY:

     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.)

    www.acthouston.com www.act-dallas.com www.act-austin.com

     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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