Substitute Teacher Form

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* 1. Please complete the following contact information.

Name

Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 2. Social Security No.

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* 3. If hired, can you provide proof that you are eligible to work in the United States?

Yes

No

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* 4. Have you ever been convicted of an offense involving the sexual molestation, physical, or sexual abuse of a child?

Yes

No

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* 5. Have you ever been convicted of a felony?

Yes

No

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* 6. North Dakota Educators License Number

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* 7. Teaching Experience

Institution - Name and Location

Dates

Grades/Subjects

Name of Supervisor/Title

Phone #

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* 8. Where do you prefer to teach? Check as many that apply

Jefferson (K-3)

Washington (4-6)

Junior/Senior High (7-12)

Special Education

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* 9. References

Name and Title of Reference

Company and Phone #

Address

Relationship