110 Stevens Ave.
Coulee
Dam, Washington 99116
(AN EQUAL OPPORTUNITY EMPLOYER)
APPLICATION FOR SUBSTITUTE EMPLOYMENT
Name: Date of Application:
Address:
City, State, Zip:
Social Security #:
Phone #: Alternate Phone #:
Candidates must hold a valid Washington
State Teaching Certificate. Please bring or mail your certificate
to this office to be registered.
Washington State Certificate Number:
Are you or have you ever been a member
of the Washington Teachers Retirement System?
Yes If yes, Plan I, Plan
II, Plan III Membership No.
No
Have you withdrawn contributions?
Yes
No
GRADE LEVEL/SUBJECTS YOU PREFER TO
TEACH:
Professional References:(No
relatives please)
NameAddressPhone
Personal References:(No relatives
please)
NameAddressPhone
Educational Training
Name
of College Location Dates
Degree Month/Year Major Minor
Grade Point Quarter
Or University
Inclusive
Graduation
Average Hours
Graduate Work:
Teaching Experience – List most
recent experience first. Include student teaching only if you
are a beginning teacher.
Dates
Name of Location Number
Grade and Subjects
Reason for Indicate Sub,
From-To School
of years Taught and Position held
Leaving Full time or S.T.
Total years of full-time contracted
teaching experience:
Experience – List most recent first.
Include any volunteer service positions.
Dates
Name of Employer Location
Type of work – Full Reason
for Leaving
From-to
or Part - Time
I hereby authorize the Grand Coulee
Dam School District to inquire as to my record with any or all of my
former employers or references with no liability arising therefrom.
I hereby guarantee the correctness of the above statements. The
making of any false statement herein will be a sufficient cause for
dismissal.
SignatureDate