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Personal Information
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Date of Application ex: 5/2/02* |
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Last Name *
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First Name *
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Middle Name *
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Maiden Name *
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Present Address *
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E-mail Address *
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City *
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State *
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Zip Code *
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Work Phone *
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The following information is needed for SBEC reports:
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- Race (optional)
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- Sex (optional)
- Male Female
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Social Security Number (If you choose not to add your SSN here for security reasons you must add it to your application fee when submitted. Applications can not be processed without this information)
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Date of Birth*
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- Yes No *
- Have you ever been convicted of a felony or offense involving moral turpitude (including, but not limited to theft, rape, murder, and indecency with a minor) and/or received probation or deferred adjudication?
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- If yes, explain.
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Educational Background
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| College/University Degreed From *, Degree *, Major *, Date of Degree *
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Employment Experience
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Do you hold a valid Texas teaching certificate? Yes No *
Please specify area(s): *
How many years of teaching experience do you have?
Are you presently employed? Yes No *
If yes, may we contact you at work? Yes No *
What district do you work for? *
What ESC region are you employed in? *
Mark the appropriate certification if you have taken and passed the TA or TE TExES exam? TA TE *
If TA/TE certified without the TExES exam what organization recommended you for certification?
List your three references. Include in the address for each reference the city, state and zip. You will need to have them send letters of reference to the address at the bottom of the application form.
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Reference Name
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Email
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Address
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Job Title: Current Sup
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Reference Name
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Email
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Address
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Job Title
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Reference Name
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Email
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Address
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Job Title
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Additional technology skills and/or knowledge: *
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Teacher Applicant Question
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In the space provided, answer the following questions. Please keep it brief. *
What MTTC session are your applying for?
Fall 08 Spring 09
Fall 09
Spring 10
What teaching experiences
have you had in the area of technology? (Please do not hit enter for a new line.)
What mentoring experiences have you had in the teaching field? (Please do not hit enter for a new line.)
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Basic Information
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Applicants will not be considered for acceptance until the following documents are on file:
- Application (completed and submitted)
- Application Fee (don't forget to record your SSN on the check or money order when sending this fee if you are not submitting SSN here)
- MTTC Pre-Preparation Online Course completion with a recommendation to MTTC status. Exemptions are:
- ESC Region II TATC program graduate or
- Technology Applications/Technology Education TExES score documentation
- Three recommendation reference letters from those familiar with the candidate's academic abilities and experience in teaching with technology (including current supervisor)
- Copy of Service Record
- Copy of Teaching Certificate/s
A letter will notify accepted applicants. Individuals not meeting requirements will be notified of their deficiency.
Send all documentation and fees concerning the program to:
- Connie Swiderski
- ESC Region II MTTC Program Administrator
- Education Service Center Region II
- 3001 N. Freeway
- Fort Worth, TX 76106
- cswiderski@esc11.net
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Signature of Agreement |
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I do hereby attest that this information is correct and current and understand that if all information is not submitted, the application process will be delayed. By submitting this application you are agreeing with the above statement.
Name *
Date ex:8/9/02*
Records are kept on file for two years.
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