Pickaway County Educational Service Center Ty Ankrom, Superintendent 2050 Stoneridge Drive e-mail: [email protected] Circleville, Ohio 43113 Shannon Clark, Treasurer Telephone: 740-474-7529 Fax: (740) 474-7251 You have indicated an interest in being placed on our list of substitute teachers for the 2013-2014 school year. Please fill out the information requested below and return to the Educational Service Center at your earliest convenience along with the items that are listed at the bottom of this form. I have no preference as to the schools in which I teach. *If interested in Brooks Yates or Crossroads, please indicate below. I wish to teach only in the schools checked below. Logan Elm Local Schools Teays Valley Local Schools Westfall Local Schools Circleville City Schools Logan Elm High School Teays Valley High School Westfall High School Circleville High School McDowell (Middle School) Teays Valley East Middle School Westfall Middle School Everts Middle School Laurelville (Grades K - 4) Teays Valley West Middle School Westfall Elementary Atwater (Grades PK - 1) Pickaway (Grades K - 4) Ashville Court Street (Grades 4 & 5) Washington (Grades K - 4) Scioto Nicholas Drive (Grades 2 & 3) Salt Creek (Grades 5 & 6) South Bloomfield *Brooks Yates School Yes No Walnut *Crossroads Christian Academy Yes No Name Street Address City Zip Code Date of Birth Social Security Telephone Cell Telephone Are you a retired employee receiving Email Address benefits from STRS? Yes No UNEMPLOYMENT COMPENSATION NOTICE Service in covered employment may render an individual eligible for Unemployment Compensation benefits. However, Ohio law may impose a "between terms" disqualification for school employees. School employees may not be paid benefits for any week of unemployment that occurs between two successive academic years or terms or during an established and customary vacation period or holiday recess. Please consult the Ohio Department of Job and Family Services for specific questions regarding Unemployment Compensation benefits. Signature: __________________________________________________________________ Date: ______________________ NOTE: A completed application includes the following: Copy of current teaching license or substitute teaching license OR completed ODE Substitute Teaching License Application Copy of college transcripts Completed Applicant's Statement Completed Employment Eligibility Form (I-9) - original IDs have to be presented, examined and photocopies at the ESC Copy of BCI and FBI Reports (within 1 year) If you do not have, call to schedule an appointment for WebCheck Fingerprinting Substitute Teacher Training Certificate of Participation (exempt from this requirement if degree is in education).