| Personal Information: |
Name: |
|
Address: |
|
School District: |
|
School/Organization: |
|
If
Retired, |
|
Most
Recent School District: |
|
Most Recent School/Organization: |
|
Home Phone: |
|
Work Phone: |
|
*E-mail: |
|
*Note: To be an External Reviewer
you will need an email address. Be sure you write
it correctly. |
| |
|
|
You
may check more than one box in any category,
if applicable: |
| |
|
|
| 1. Current
Status |
|
Classroom Teacher |
|
School/District Administrator |
|
Curricular or Instructional Support Personnel |
|
Post Secondary Teacher Educator |
|
Retired Educator |
|
Other - Specify:
|
| 2. Level
of Professional Licensure |
|
Level II |
|
Level III-A |
|
Level III-B |
|
National Board Certification |
|
Other - Specify:
|
| 3. Type
of Professional Licensure |
|
Early Childhood, Birth-Grade 3 |
|
Elementary, K-8 |
|
K-12 Teaching |
|
Middle Level Teaching, 5-9 |
|
Secondary Teaching, 7-12 |
|
Special Education, K-12
Specify Type:
(i.e.,
behavioral disorders, severe disabilities, etc):
|
|
Secondary Vocational-Technical |
|
Blind/Visual Impairment B-12 |
|
Other - Specify:
|
| 4. Teaching
Endorsements |
|
Agriculture |
|
Bilingual |
|
Business Education |
|
Family and Consumer Science |
|
Fine Arts |
|
Health Education |
|
Language Arts |
|
Library/Media |
|
Mathematics |
|
Modern, Classical and Native Languages |
|
Music |
|
Performing Arts (Music-Dance-Theater) |
|
Physical Education |
|
Psychology |
|
Reading |
|
Science |
|
Social Studies |
|
Technology Coordinator |
|
Technology Education |
|
Teaching English to Speakers of Other Language |
|
Visual and Performing Arts |
|
Other - Specify:
|
5. Total
Years of Teaching Experience
Check
the category that best describes your teaching experience: |
|
5 Years minimum of P-12 Teaching Experience |
|
5 Years minimum Combined P-12 Teaching and School
Administration Experience |
|
5 Years minimum Combined P-12 Teaching and Post
Secondary Teacher Education Experience
|
6. P-12
Grade Levels You Teach or Have Taught
Respond
to all that apply: |
| |
|
Grade |
Years of Teaching Experience |
|
|
Pre-K |
|
|
|
K |
|
|
|
1 |
|
|
|
2 |
|
|
|
3 |
|
|
|
4 |
|
|
|
5 |
|
|
|
6 |
|
|
|
7 |
|
|
|
8 |
|
|
|
9 |
|
|
|
10 |
|
|
|
11 |
|
|
|
12 |
|
7. Subject
Areas You Teach or Taught:
You
MUST complete this section in order for your application
to be considered. |
| |
Subject Area |
Years of Teaching Experience |
|
Agriculture |
|
|
Business Education |
|
|
Family and Consumer Science |
|
|
Fine Arts |
|
|
Health Education |
|
|
Language Arts |
|
|
Library/Media |
|
|
Mathematics |
|
|
Modern, Classical and Native Languages:
|
|
|
Specify Language(s) Taught:
|
|
Music |
|
|
Performing Arts
(Music-Dance-Theater) |
|
|
Physical Education |
|
|
Psychology |
|
|
Reading |
|
|
Science |
|
|
Social Studies |
|
|
Technology |
|
|
Teaching English to Speakers of Other Languages |
|
|
Visual and Performing Arts |
|
|
Other - Specify:
|
|
8. Write
a Short Statement (up to 100 words) on The Knowledge,
Experience,
and Expertise You Will Bring to The PDD Review Process: |
|
After
reviewing your form to make sure you have completed
ALL sections of the application, press the Submit
button below to send your application. |
|
Thank you for applying.