Energized for STEM Academy

1. Last Name: First Name: Middle: Date Available:
2. Present Address: City: State, Zip: Phone Number:
3. Permanent Address: City: State, Zip: Phone Number:
4. Former Name Used:

Can you, after an offer of employment, submit verification of your legal right to work in the US? Yes No

Veteran's priority - A veteran qualifies for a veteran's employment priority if the veteran served in the Army, Navy, Air Force, Marine Corps, Coast Guard of the U.S., or in an auxiliary service of those branches,

• - Or served in the military for not less than 90 consecutive days during a national emergency declared in accordance with the federal law,
• - was honorably discharged
• - and is found to be equally qualified with other applicants.




Do you qualify for this priority? Yes No


If employed, employee will be asked to provide documents to support qualifications (DD214).
No one convicted of any felony or misdemeanor involving moral turpitude will be considered for employment with Energized For Stem, Inc.




Colleges/Universities Attended	Dates Attended (From - To)	Graduation Date	Degree	Major/Subject
			Degree TypeA.AA.S.A.A.SA.E.A.A.A.A.P.S.B.A.B.S.B.F.AB.B.A.M.A./M.F.A.M.S.M.ResM.PhilM.B.A.PhDM.D.Ed.D
			Degree TypeA.AA.S.A.A.SA.E.A.A.A.A.P.S.B.A.B.S.B.F.AB.B.A.M.A./M.F.A.M.S.M.ResM.PhilM.B.A.PhDM.D.Ed.D
			Degree TypeA.AA.S.A.A.SA.E.A.A.A.A.P.S.B.A.B.S.B.F.AB.B.A.M.A./M.F.A.M.S.M.ResM.PhilM.B.A.PhDM.D.Ed.D
			Degree TypeA.AA.S.A.A.SA.E.A.A.A.A.P.S.B.A.B.S.B.F.AB.B.A.M.A./M.F.A.M.S.M.ResM.PhilM.B.A.PhDM.D.Ed.D

Type of certificate held now: Valid Texas


Valid Other State
None
Deficiency Plan: (specify)





Areas of Certification: Elementary


Secondary (Middle and High)
Special Education (Specify)
All level art
All level health and PE
Librarian
Counselor
Nurse
Vocational (Specify)
Others (Specify)





Position Applied for (specify):

I am also interested in being a substitute.
I am only interested in being a substitute.

Student-Teaching Information (attach college placement file if recent graduate)

1. From/To (Month/Year)
2. Name of Cooperating Teacher(s)
3. Name of School and District Address, City, State, Zip
4. Subject or Grade Level
5. Subject or Grade Level
6. Name of University Supervisor
7. Name of University, Address, City, State, Zip

Work and/or Teaching Experience: Please provide a complete listing of all work/teaching positions you have held. Begin with most recent. Please attach listing of other employers, if applicable.





From/To (Month/Year)	Name of Company/School Address, City, State, Zip	Name/Title of Supervisor	Telephone Number	Work Performed	Reason for leaving

Please attach any files (Resumes, Certificates, &c. here):
Have you ever been employed by Energized for STEM Academy, Inc. organization?

Under what name? Date:
I hereby give you permission to complete a reference from furnished by Energized for STEM Academy to release the form with recommendations.

I certify that the above information is true, accurate and complete. I understand that any misrepresentation or willful omission of fact shall be sufficient cause for disqualification of this application from further consideration or termination of employment.
Any additional information you'd like to present can be input here:
Signature of Applicant (Full Name)
Date
ENERGIZED FOR STEM ACADEMY, INC.STATEMENT OF NONDISCRIMINATION: It is the policy of our Academynot to discriminate or engage in harassment on the basis of race, color, national origin, sex, religion, age, disability, or any other legally protected status in its educational and vocational programs, services oractivities or matters related to employment as required by Title VI and Title VII of the Civil Rights Act of 1964, as amended; Title IX of the Education Amendments of 1972; Age Discrimination in Employment Act; Americans with Disabilities Act, as amended; and Section 504 of the Rehabilitation Act of 1973, as amended.Inquiries regarding the Academy’snon-discrimination policies in the following areas should be directed to: Argentina M. James, Director of Human Capital at 713.641.1630 or ajames11@houstonisd.org