<p> PULLMAN SCHOOL DISTRICT NO. 267 240 SE Dexter Street • Pullman, WA 99163 Personnel Office (509) 332-3584 • FAX (509) 334-0375</p><p>APPLICATION FOR CERTIFICATED EMPLOYMENT</p><p>Thank you for applying for a position in the Pullman School District. To be considered for an interview, the following application materials must be received in the Personnel Office by the closing date. Only complete application packets will be reviewed. </p><p>Pullman School District application - PLEASE COMPLETE ALL SECTIONS ON THE APPLICATION FORM Applicant Disclosure Statement Formal typed letter of application addressing qualifications Current resume Copy of your Washington State Certificate(s) or evidence of application for a Washington Certificate Copy of all college transcripts (official copies will be required before a contract is issued) Copy of test scores/reports (West-B, West-E/Praxis II), if applicable Three letters of recommendation or a placement file (can be sent directly to the Pullman School District) Affirmative Action Form (completion of this form is voluntary) </p><p>DATE: POSITION (S) FOR WHICH YOU ARE APPLYING: </p><p>PERSONAL INFORMATION Last Name First Name MI</p><p>Other Names Used Social Security Number</p><p>Temporary Address City State Zip</p><p>Permanent Address City State Zip</p><p>Telephone Message Number Email</p><p>CERTIFICATION AND ENDORSEMENTS (please indicate if certification is pending & date of application) Type Number Date Issued Expiration Endorsements Date</p><p>Test Scores (West-B, West-E/Praxis II), if applicable - please include copy of test result reports with your application EDUCATION EDUCATION AND TRAINING (list most recent first) Name of Institution Dates Attended Degree Date of Major Minor GPA City, State Mo/Yr to Mo/Yr Degree</p><p>PROFESSIONAL PREPARATION (please check all that apply and indicate your preparation) Topic Dates Indicate preparation/experience State Assessments</p><p>Reading Instruction </p><p>Writing Instruction </p><p>Mathematics Instruction </p><p>Science Instruction </p><p>Special Education and 504 Accommodations</p><p>Highly Capable - Advanced Placement</p><p>Differentiated Instruction</p><p> Technology </p><p>Other professional preparation (please list): </p><p>Cultural Competence and Responsiveness</p><p>COACHING/ADVISING STUDENT GROUPS (please list activities of interest and background in said activity - coaching, academic teams, clubs, tutoring)</p><p>EMPLOYMENT EXPERIENCE CERTIFICATED CONTRACTED EXPERIENCE (list most recent first) District Name Address Dates Position Title Reason for Leaving Phone Number City, State, Zip Mo/Yr to (Grade (s) and/or Mo/Yr subject (s) taught)</p><p>CERTIFICATED SUBSTITUTE EXPERIENCE (include prior Pullman School District experience) District Name Address Dates Position Title Reason for Leaving Phone Number City, State, Zip Mo/Yr to (Grade (s) and/or Mo/Yr subject (s) taught)</p><p>STUDENT TEACHING EXPERIENCE District Name Address Dates Position Title Master Teacher/ Phone Number City, State, Zip Mo/Yr to (Grade (s) and/or Principal Mo/Yr subject (s) taught)</p><p>OTHER EMPLOYMENT EXPERIENCE (list most recent first) Employer Address Dates Position Title Reason for Leaving Phone Number City, State, Zip Mo/Yr to Mo/Yr</p><p>MILITARY EXPERIENCE Branch of Service Duties Dates Total Years Mo/Yr to Mo/Yr</p><p>REFERENCES (professional only – do not list friends or relatives) Name Position / Relationship </p><p>Address , City, State Zip Telephone Home: Business:</p><p>Name Position / Relationship </p><p>Address , City, State Zip Telephone Home: Business: </p><p>Name Position / Relationship </p><p>Address , City, State Zip Telephone Home: Business: </p><p>Name Position / Relationship </p><p>Address , City, State Zip Telephone Home: Business: </p><p>• I hereby authorize the Pullman School District to make any investigation of my personal or employment history and authorize any former employer, person, or organization to give Pullman School District any information regarding me. I release the Pullman School District, its employees and/or agents and all providers of information from any liability as a result of furnishing and receiving this information. </p><p>• I certify that the information presented in this application is true and complete to the best of my knowledge, and I have read and understand that I have authorized the district to conduct reference checks. I further agree that if I am employed, I will provide verification of my certification, education, and experience. I understand if I am employed, false statements on this application may be cause for dismissal. </p><p>Signature Date </p><p>PULLMAN SCHOOL DISTRICT MAINTAINS A TOBACCO FREE AND DRUG FREE ENVIRONMENT</p><p>PULLMAN SCHOOL DISTRICT IS AN EQUAL OPPORTUNITY EMPLOYER</p><p>The Pullman School District does not discriminate in any programs or activities on the basis of sex, race, creed, religion, color, national origin, age, veteran or military status, sexual orientation, gender expression or identity, disability, or the use of a trained dog guide or service animal and provides equal access to the Boy Scouts and other designated youth groups. The following employee has been designated to handle questions and complaints of alleged discrimination: Assistant Superintendent, Pullman School District Administrative Offices, 240 SE Dexter Street, Pullman, WA 99163, (509) 332-3144, [email protected]. Applicants with disabilities may request reasonable accommodations in the application process by contacting the Human Resources Manager at (509) 332-3584.</p>