<p> Voluntown Board of Education 195 Main Street, P.O. Box 129 Voluntown, Connecticut 06384 Tel: (860) 376-9167 Fax: (860) 376-3185</p><p>APPLICATION FOR SUBSTITUTE TEACHING</p><p>Name:______Last First Middle Address:______Street City/Town State/Zip Telephone (Home):______(Cell):______</p><p>Are you eligible to work in the United States? Yes___ No___ SSN_____-____-_____</p><p>EDUCATION:</p><p>1. ______College/University Name & Location Years Attended Year Graduated Degree</p><p>2. ______College/University Name & Location Years Attended Year Graduated Degree</p><p>3. ______High School Name & Location Years Attended Year Graduated</p><p>Do you have a valid Connecticut Teaching Certificate?_____ If yes, type:  Initial  Provisional  Professional ______Area of Certification Held Since Applied For State Expiration</p><p>Proper certification is the responsibility of the applicant. A copy of your college/university transcripts (or proof of your degree) must accompany your application.</p><p>EDUCATIONAL EXPERIENCE BEGINNING WITH STUDENT TEACHING (if applicable):</p><p>______Nature of Position School Location Dates</p><p>______Nature of Position School Location Dates</p><p>______Nature of Position School Location Dates</p><p>1 EMPLOYMENT HISTORY (starting with most recent):</p><p>Firm:______Address:______Dates Employed:______Position/Title:______Reason for Leaving:______</p><p>Firm:______Address:______Dates Employed:______Position/Title:______Reason for Leaving:______</p><p>Firm:______Address:______Dates Employed:______Position/Title:______Reason for Leaving:______</p><p>Have you ever been convicted of a crime? ____ If yes, explain______</p><p>______</p><p>REFERENCES:</p><p>1.______Name Position Address Telephone No.</p><p>2.______Name Position Address Telephone No.</p><p>3.______Name Position Address Telephone No.</p><p>In signing this application, I do hereby verify that all information I have presented is true and accurate to the best of my knowledge. I understand that, if hired, willful misrepresentation may result in my immediate dismissal. I agree to release and to hold harmless the Voluntown Board of Education and Administration from any liability associated with the hiring process, and to release all previous employers and references from liability in providing the Voluntown Board of Education with information about me.</p><p>I do further agree to release and to hold harmless the Voluntown Board of Education and Administration from any liability for information that they may provide to potential and/or future employers.</p><p>______Signature of Applicant Date</p><p>THE VOLUNTOWN BOARD OF EDUCATION IS AN EQUAL OPPORTUNITY EMPLOYER AND COMPLIES WITH THE REGULATIONS SET FORTH UNDER TITLE IX.</p><p>Revised 09/12</p><p>2</p>