Substitute Position(s): 

Name (First Name, Last Name): 

Email: 

Street Address: 

City, State, Zip: 

Primary Phone #: 

Secondary Phone #: 

U.S. Citizen?
 YES
 NO

Do you have a New Jersey Instructional Certificate?
 YES
 NO

If you answered Yes to having a NJ Instructional Certificate, please list Certificate(s) below (please include Cert. type, i.e. Standard, CE or CEAS):

Do you have a valid New Jersey Substitute Credential?
 YES
 NO

Have you completed the fingerprint process specifically for school employment?
 YES
 NO

Are you currently employed as a substitute teacher for a NJ school district or educational agency (i.e. Source4Teachers)?
 YES
 NO

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EDUCATION:

High School Attended (Name/Location): 

College/University (1): 

     Dates Attended: 

     Degree/Major: 

College/University (2): 

     Dates Attended: 

     Degree/Major: 

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EMPLOYMENT (please list most recent employment first):

Employer/Location (1): 

    Position: 

     Dates (From-To): 

Employer/Location (2): 

    Position: 

     Dates (From-To): 

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Community Activities and Interests:

References (please list 3 references - include phone number and/or email address):

When would you be available to work (following completion of required paperwork)?

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Acceptance of Terms:

 By checking this box, I affirm that all of the above information is correct and fully authorize an investigation to confirm the validity thereof. Furthermore, I understand that any misrepresentation or omission of facts will result in immediate dismissal.

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