<p> 2012 SPECIAL EDUCATION EXTENDED SCHOOL YEAR (ESY) PROGRAM APPLICATION June 27 (Workday) – July 26, 2012</p><p>Please check one:</p><p>Position Grade Level Teacher □ Disability □ ECSE □ Nurse □ LD □ Elementary □ Teacher Assistant □ ED □ Middle □ Speech Pathologist □ ID □ High □ Interpreter □ AUT □ Substitute Teacher □ HI □ Substitute Teacher Assistant □ OTHER ______</p><p>NAME______ID#______</p><p>ADDRESS______Number & Street City State Zip TELEPHONE: Cell______Home______</p><p>CERTIFICATE:</p><p>*Do you have a Virginia Teacher’s Certificate? □ YES □ NO If yes, what grades and/or subject area(s) are you endorsed to teach? (List)</p><p>______</p><p>*Do you have a Teacher’s Certificate from a state other than Virginia? □ YES □ NO</p><p>EXPERIENCE:</p><p>Current Teaching Position: </p><p>Division: ______</p><p>______SCHOOL ASSIGNMENT SUBJECT(S) GRADE LEVEL LENGTH OF SERVICE</p><p>Previous Teaching Position: </p><p>Division: ______</p><p>______</p><p>SCHOOL ASSIGNMENT SUBJECT(S) GRADE LEVEL LENGTH OF SERVICE Have you previously been employed as an ESY teacher with Suffolk Public Schools?</p><p>□ YES □ NO IF YES, □ ECSE □ Elementary □ Middle □ High </p><p>CATEGORY: ______</p><p>Have you ever been convicted of any offense involving the sexual molestation, physical, or sexual abuse or rape of a child?</p><p>□ YES □ NO</p><p>I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge. I understand that if employed, falsified statements on this application shall be considered sufficient cause for dismissal. You are hereby authorized to make any investigation of my personal or professional history.</p><p>______Applicant’s Signature Date</p><p>Applications from present employees are to be submitted through the principal. Applications from persons not currently employed by our school division must be submitted to: Human Resources Dept. P.O. Box 1549 Suffolk, VA 23439-1549</p><p>APPLICATIONS MUST BE COMPLETED AND RETURNED TO Jasmine Downs BY APRIL 6, 2012.</p><p>FROM PRINCIPAL: (This section ONLY for employees currently under contract with Suffolk Public Schools)</p><p>RECOMMENDATION □ I Do Recommend □ I Do Not Recommend</p><p>Specific Comments: ______</p><p>______Principal’s Signature Date</p><p>Suffolk City Public Schools does not discriminate on the basis of race, color, national origin, sex, disability, or age in its programs and activities. The following person has been designated to handle inquiries regarding the non-discrimination policies.</p><p>Kevin L. Alston, Assistant Superintendent of Administrative Services 100 N. Main Street P.O. Box 1549 Suffolk, VA 23439-1549 Phone: (757) 925-6750 Fax: (757) 925-6751 Email: [email protected]</p>