Applicant Information * Indicates a required field Full Name: * Home Phone:* Cell Phone: Email Address:* Certified?* Yes   No Address1:* Address2: City* State* AB AK AL AR AZ BC CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NB NC ND NE NF NH NJ NM NS NT NU NV NY OH OK ON OR PA PE PQ PR QC RI SC SD SK TN TX UT VA VI VT WA WI WV WY YT Zip Code* How did you hear about us?* Friend Family Member Yellow Pages Google Search MSN Search Other Internet Search Radio TV Newspaper Ad Parent Magazine Other Education/Background (indicate name of school/location and yrs completed) High School: College: Degree(s): Other areas of study: Do you have any special skills or training that will aid in the development of our students? Other skills and/or training: Yes   No If yes, explain: What Grades/Subjects would you like to teach? Current Employer*   Name Address Dates of employment Job Description Name of Supervisor Please Describe Prior Tutoring Experience:* Comments: Professional References Name: Phone: Years Known: Email:   Name: Phone: Years Known: Email: Official background information Have you ever been convicted of any crime, whether a misdemeanor or felony?* Yes   No If yes, when, where and for what crime? Will you submit to a drug and background test if necessary? * Yes   No Do you agree to a background investigation including a criminal background investigation?* Yes   No I certify that the information I have provided on all the pages above is true, accurate and correct: Signature Date
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