Substitute Teacher Application Form
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1
2HARRISON CENTRAL SCHOOL DISTRICT
10528
50 Union Avenue, Harrison, New York
Web Page:
Telephone : (914) 835-3300
APPLICATION FOR SUBSTITUTE TEACHING
Date:_______________
Name ______________________________________________________________________________________________
Last
First
Middle
Other Name(s) _______________________________________________________________________________________
(Please provide any additional information regarding maiden name, change of name, use of an
assumed name or nickname which is necessary to enable a check of your work or school records.)
Address ____________________________________________________________________________________________
___________________________________________________________________________________________________
E-Mail Address______________________Telephone No. ____________________Social Security No.________________
N.Y.S. Retirement System Member?
Yes
No
If yes, please indicate number _______________________
ڤ
ڤ
Have you ever been dismissed or asked to resign from a position?
Yes
No ڤIf yes, please explain _________
ڤ
___________________________________________________________________________________________________
Have you ever been convicted of a crime other than a minor traffic violation? Yes ڤNo ڤ
If yes, please explain on a
separate sheet, citing date, offense and disposition of case.
Have you been fingerprinted? Yes ڤ
No ڤ
If yes, where? ___________________________ Date____________
Are you legally eligible to work in the United States? Yes
No
Can you perform the essential functions of the job with or without a reasonable accommodation? Yes
No
NEW YORK STATE TEACHER CERTIFICATES
Number
Perm.
Prov.
C.Q.
Area or Subject
Date Issued
____________________________________________________________________________________________________
____________________________________________________________________________________________________
SUBSTITUTE AREA: Check area(s) of certification. Check other areas of capability ONLY if EXPERIENCED
and COMPETENT in those subjects.
SUBJECT AREA
CERT.
EXPER’D.
SUBJECT AREA
CERT.
EXPER’D.
Art
(
)
(
)
Music: Elem. Instru.
(
)
(
)
Business: (Shorthand, Type,
(
)
(
)
Elem. Vocal
(
)
(
)
Law, Bkkpg., etc.)
(
)
(
)
Music : Sec. Instru.
(
)
(
)
Computers
(
)
(
)
Sec. Vocal
(
)
(
)
Elementary
(
)
(
)
Physical Ed. : Elem.
(
)
(
)
English
(
)
(
)
Sec.
(
)
(
)
Health
(
)
(
)
Remedial Reading
(
)
(
)
Home Economics
(
)
(
)
Science: Biology
(
)
(
)
Industrial Arts
(
)
(
)
Chemistry
(
)
(
)
Languages: French
(
)
(
)
Earth Science
(
)
(
)
Latin
(
)
(
)
Physics
(
)
(
)
Spanish
(
)
(
)
Social Studies
(
)
(
)
Italian
(
)
(
)
Special Education
(
)
(
)
Library/Media
(
)
(
)
Other: Specify
Mathematics
(
)
(
)
______________________
(
)
(
)
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