CERTIFICATED EMPLOYMENT APPLICATION

Human Resources Services

Middle Name 44711 North Cedar Avenue
Lancaster, California 93534
661-948-4661

Position(s) for which you are applying (Grade and/or Subject)

First Name

Name Social Security Number

( )
Street Address Telephone (Home)

( )
City/State/Zip Code Telephone (Other)
Last Name

Education and Professional Training

Units Degree or Date
Institution of Higher Education Dates Attended Major
Sem/Qtr Certificate Conferred
PRINT NAME HERE:

Semester units of graduate work beyond BA or BS degree (1-Quarter Unit equals 2/3 Semester Unit)
BA BA+15 BA+30 BA+45 or MA MA+15 or BA+60 MA+30 or BA+75

Awards, Honors, Scholarships, etc., which you feel relate to this position:
An Equal Opportunity-Affirmative Action Employer

What languages other than English can you speak?

Lancaster School District

List extra-curricular activities you participated in college.

List Professional, Technical, Educational, Community, or Service Organizations to which you belong.
(Omit religious, racial, or ethnic organizations)

Please complete the following fitness questions. If you answer “yes” to any question, please attach a
full explanation using a separate sheet of paper.
Have you ever been dismissed, retired, resigned from, suspended for more than ten
days, or otherwise left school employment because of allegations of misconduct? Yes No

Have you ever been convicted, including a conviction based on a plea of no contest,
of any felony or misdemeanor in California or any other place? Yes No

Have you ever been or are you currently the subject of any inquiry or investigation by
any licensing agency or law enforcement agency (in California or any other state)? Yes No

Have you ever been convicted of any moving traffic violations? Yes No

Are any criminal charges currently pending against you? Yes No

Is any disciplinary action now pending against you in any school district? Yes No
Credential Information:
Have you passed all sections of the CBEST test? Yes No

Do you hold a valid California Credential? Yes No

Type of Credential Expiration Date of Credential

Do you hold a valid California Teaching Permit? Yes No

Type of Permit Expiration Date of Permit

Are you currently enrolled in a teacher preparation program? (If yes, please complete the
following) Yes No

Institution of Higher Education Credential Program

Have you passed subject matter competency? (MSAT/CSET) Yes No

Have you ever had any credential, including, but not limited to, any Certificate of Clearance, permit, Yes No
credential, license, or other document authorizing public school service or teaching, privately
admonished within the past three years, publicly reproved, suspended, revoked, voided, self-
revoked, and/or otherwise subjected to any other disciplinary action in California or any other place?

Have you ever had any application for a credential, including but not limited to, any Certificate of Yes No
Clearance, permit, credential, license, or other document authorizing public school service or
teaching, denied and/or rejected for cause in California or any other state or place?

I certify that all statements on this application are true to the best of my knowledge. I understand that false statements
shall be sufficient cause for dismissal or disqualification from employment consideration.

Signature of Applicant Date

Your employment application should include:

Lancaster School District application

Resumé (include Professional and Personal References)
Copy of transcripts
Copy of your teaching credential
Letters of reference (no more than three)

If you have any questions, please contact Human Resources Services.

Telephone: (661) 948-4661 Extension 151

E-mail: jims@lancsd.org