APPLICATION Date of application: Pg 1/2
Where are you applying? ；act？houston ；act？dallas ；act？austin
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)
_ EDUCATIONAL BACKGROUND
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.
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
？ 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.
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 act？dallas 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