DISTRICT INTERN PROGRAM

APPLICATION
SINGLE SUBJECT / MULTIPLE SUBJECT / EDUCATION SPECIALIST / ECO
PLEASE PRINT IN BLACK INK OR TYPE ALL INFORMATION REQUIRED. INCLUDE OFFICIAL TRANSCRIPTS, COPIES OF CBEST, US CONSTITUTION
REQUIREMENT, SUBJECT MATTER TEST SCORES (OR WAIVER), RESUME, ESSAY, THREE PROFESSIONAL RECOMMENDATIONS ON REQUIRED FORM,
CERTIFICATE OF CLEARANCE, AND A NON-REFUNDABLE APPLICATION FEE WITH YOUR APPLICATION. (ALTHOUGH THE INFORMATION BELOW MAY BE
ON YOUR RESUME, IT MUST ALSO BE COMPLETED ON THE APPLICATION.) ALL MATERIALS MUST BE RECEIVED IN THE
SACRAMENTO OFFICE NO LATER THAN THE POSTED DEADLINE: MARCH 5 FOR EARLY BIRD DEADLINE ($60
APPLICATION FEE), APRIL 1 FOR THE REGULAR DEADLINE ($75 APPLICATION FEE), OR APRIL 30 FOR THE LATE
DEADLINE ($100 APPLICATION FEE).

PROGRAM CHOICE: PLEASE CHECK THE BOX OF THE PROGRAM TO WHICH YOU ARE APPLYING:
SINGLE SUBJECT

MULTIPLE SUBJECT

EDUCATION SPECIALIST

ECO

PERSONAL INFORMATION:
MR.
MS.
MRS. ______________________________
LAST NAME

______________________ __________
FIRST NAME
MI

_______________________.________
EMAIL ADDRESS

__________ - __________ - __________

SOCIAL SECURITY NUMBER

( _______ ) _________ - ____________

CELL OR HOME PHONE

________ / ________ / ___________

DATE OF BIRTH

_____________________________ @

CURRENT MAILING ADDRESS: (UNTIL ___________________)

PERMANENT MAILING ADDRESS:

______________________________________________
STREET

______________________________________________
STREET

____________________________ ________ _________

CITY
STATE
ZIP

____________________________ ________ _________

CITY
STATE
ZIP

ARE YOU A UNITED STATES CITIZEN?

IF NO, HOW ARE YOU AUTHORIZED TO WORK IN THE UNITED

STATES?

YES

NO

HAVE YOU EVER BEEN CONVICTED OF, OR ENTERED A PLEA OF NO CONTEST TO ANY FELONY OR MISDEMEANOR OTHER THAN A TRAFFIC
VIOLATION?
YES
NO
IF YES, PLEASE ATTACH AN EXPLANATION IN A SEALED ENVELOPE.
PLEASE CHECK THE BOX THAT APPLIES TO YOU (OPTIONAL):
AFRICAN-AMERICAN
AMERICAN INDIAN/ALASKAN NATIVE
ASIAN
LATINO
WHITE
PACIFIC ISLANDER
OTHER: SPECIFY _______________________________
TESTING REQUIREMENTS:
HAVE YOU TAKEN AND PASSED THE CALIFORNIA BASIC EDUCATION SKILLS TEST (CBEST)?
YES
DATE PASSED: _______________
NO
I AM AWAITING SCORES FROM TEST TAKEN ON (DATE) _______________ AND WILL PERSONALLY FORWARD THE SCORES
TO FORTUNE SCHOOL OF EDUCATION. (NOTE: SCORES ARE NOT FORWARDED BY TESTING AGENCY WHEN REQUESTED)
HAVE YOU TAKEN AND PASSED THE CALIFORNIA SUBJECT EXAMINATION TESTS FOR TEACHERS (CSETS)?
YES
DATE PASSED: _______________
NO
I AM AWAITING SCORES FROM TEST TAKEN ON (DATE) _______________ AND WILL PERSONALLY FORWARD THE SCORES
TO FORTUNE SCHOOL OF EDUCATION. (NOTE: SCORES ARE NOT FORWARDED BY TESTING AGENCY WHEN REQUESTED)
DO YOU HAVE A SUBJECT MATTER COMPETENCY WAIVER LETTER FROM AN APPROVED CALIFORNIA UNIVERSITY?
YES
NO
IF YES, FROM WHICH UNIVERSITY DID YOU RECEIVE YOUR WAIVER LETTER? ________________________ DATE: _______________

ADDITIONAL TESTING REQUIREMENTS (ECO ONLY):

HAVE YOU TAKEN AND PASSED THE APPROPRIATE EXAM?
YES TFE - TEACHING FOUNDATIONS EXAM (PREVIOUS TAKEN/PASSED PRIOR TO 9/26/2013)
DATE PASSED: _______
YES ASSESSMENT OF PROFESSIONAL KNOWLEDGE: ELEMENTARY (CURRENT: MULTIPLE SUBJECT) DATE PASSED: _______
YES ASSESSMENT OF PROFESSIONAL KNOWLEDGE: SECONDARY (CURRENT: SINGLE SUBJECT)
DATE PASSED: _______
NO I AM AWAITING SCORES FROM TEST TAKEN ON (DATE) _______________ AND WILL PERSONALLY FORWARD THE SCORES
TO FORTUNE SCHOOL OF EDUCATION. (NOTE: SCORES ARE NOT FORWARDED BY TESTING AGENCY WHEN REQUESTED)
HAVE YOU SUBMITTED AND PASSED TPA TASK 1: SUBJECT SPECIFIC PEDAGOGY?
YES DATE PASSED: _______________
NO I AM AWAITING RESULTS FROM TASK SUBMITTED ON (DATE) _______________ TO FORTUNE SCHOOL OF EDUCATION.
COLLEGE OR UNIVERSITY EDUCATION: (BEGIN WITH MOST RECENTLY ATTENDED EDUCATIONAL INSTITUTION)
NAME AND LOCATION OF EACH
EDUCATIONAL INSTITUTION ATTENDED

ATTENDED
FROM

DEGREE & DATE

TO

MAJOR

TEACHING EXPERIENCE (SUBSTITUTE TEACHER, TEACHERS AIDE, TUTORING, ETC.) + RESUME:

BEGIN WITH MOST RECENT EXPERIENCE. RESUME SHOULD INCLUDE A TEACHING OBJECTIVE AND LIST OF ANY TEACHING/TUTORING WORK
EXPERIENCE OR ANY OTHER EDUCATION-BASED WORK EXPERIENCE THAT YOU HAVE ACQUIRED. NON-EDUCATIONAL WORK EXPERIENCE SHOULD BE
INCLUDED AS WELL.
SCHOOL/INSTITUTION/ORGANIZATION
LOCATION

POSITION(S)

GRADE OR SUBJECT
AREA TAUGHT

DATE
FROM

TO

OTHER WORK EXPERIENCE: (BEGIN WITH MOST RECENT EXPERIENCE)

SCHOOL/INSTITUTION/ORGANIZATION
LOCATION

POSITION(S)

GRADE OR SUBJECT
AREA TAUGHT

DATE
FROM

TO

PROFESSIONAL RECOMMENDATIONS:
THREE PROFESSIONAL REFERENCES MUST BE INCLUDED WITH YOUR APPLICATION PACKAGE. FOR THESE RECOMMENDATIONS, YOU ARE
REQUIRED TO USE THE FORTUNE SCHOOL OF EDUCATION RECOMMENDATION FORM. THESE FORMS CAN BE FOUND ONLINE AT
HTTP://WWW.FORTUNESCHOOL.US/GRADUATE-SCHOOL/ADMISSIONS-DISTRICT-INTERN-PROGRAM.

NOTE: THESE FORMS MUST BE USED FOR YOUR APPLICATION TO BE CONSIDERED.

PERSONAL STATEMENT ESSAY:
A ONE-PAGE PERSONAL STATEMENT EXPLAINING YOUR MOTIVATION FOR ENTERING THE TEACHING PROFESSION AND YOUR
GOALS FOR PROMOTING STUDENT ACHIEVEMENT MUST BE INCLUDED WITH YOUR APPLICATION PACKET. THIS ESSAY MUST BE IN 12PT
TIMES NEW ROMAN FONT, DOUBLE SPACED, AND MUST ADDRESS THE PROMPT.
DO YOU HAVE A TEACHING POSITION SECURED WITH AN FSE DISTRICT PARTNER FOR 2015-2016?
YES

NO

I HAVE A CONTRACTED FULL-TIME TEACHING POSITION SECURED WITH A FORTUNE SCHOOL OF EDUCATION DISTRICT PARTNER
FOR THE 2015-2016 SCHOOL YEAR.
DISTRICT: ______________________ SCHOOL SITE: ______________________ SUBJECT: ____________________
PLEASE INCLUDE A COPY OF YOUR CONTRACT OR OFFER LETTER WITH YOUR APPLICATION PACKAGE.
I DO NOT HAVE A CONTRACTED FULL-TIME TEACHING POSITION SECURED WITH A FORTUNE SCHOOL OF EDUCATION
DISTRICT PARTNER FOR THE 2015-2016 SCHOOL YEAR.

PLEASE MARK BELOW THE COUNTY IN WHICH YOU WOULD LIKE TO TEACH AND TAKE FORTUNE SCHOOL OF EDUCATION COURSES:
SACRAMENTO (SACRAMENTO COUNTY/CAPITOL CITY/CENTRAL VALLEY)
BAY AREA
(CONTRA COSTA COUNTY/ALAMEDA COUNTY)
NO PREFERENCE
PLEASE SELECT THE SUBJECT MATTER YOU WOULD LIKE TO TEACH DURING THE 2015-2016 YEAR:
MULTIPLE SUBJECT
SINGLE SUBJECT
SPECIAL EDUCATION

SPECIFY SUBJECT OF CHOICE:

____________________________________________

DO YOU POSSESS ANY OF THE FOLLOWING?

CREDENTIAL/CERTIFICATE

YES

SPECIAL SKILLS/TRAINING:
NO

TRAINED IN ASSERTIVE DISCIPLINE

TRAINED IN CLINICAL TEACHING TECHNIQUES
MUSIC
ART
COMPUTERS
COACHING/SPORTS
OTHER: ________________________

BCLAD CERTIFICATE
CLAD CERTIFICATE
EMERGENCY PERMIT
SS/MS/ES CALIFORNIA TEACHING CREDENTIAL
LANGUAGES ABILITIES OTHER THAN ENGLISH:
LANGUAGE ABILITIES

LANGUAGE 1 (SPECIFY):
YES

LANGUAGE 2 (SPECIFY):
NO

YES

NO

SPEAK FLUENTLY
WRITE FLUENTLY
CERTIFICATION OF APPLICATION:
I HEREBY CERTIFY THAT ALL INFORMATION IN THIS APPLICATION AND IN SUPPORT OF THIS APPLICATION IS TRUE AND COMPLETED TO THE BEST OF MY
KNOWLEDGE. FALSIFICATION OF ANY INFORMATION ON THIS APPLICATION MAY BE GROUNDS FOR DISQUALIFICATION OR DENIAL OF ADMISSION OR, IF
DISCOVERED AFTER ADMISSION, GROUNDS FOR DISMISSAL FROM FORTUNE SCHOOL OF EDUCATION. I UNDERSTAND THAT I MUST NOTIFY THE
ADMISSIONS DEPARTMENT IF RESPONSES TO THE INFORMATION REQUESTED ON THIS APPLICATION CHANGE PRIOR TO ENROLLMENT.

______________________________________________

_______________________

SIGNATURE OF APPLICANT

DATE