Distinguished Professionals Education Institute

Personal Information

Date First Name Middle Name Last Name (Maiden Name) Home Address Address Line 2 City State Zip Code Home Phone Cell Phone Email Address Résumé

Note: Your résumé must be in Word (.doc) or Adobe Acrobat (.pdf) format.

Please ensure that, when requested, you can provide an official college transcript documenting that you meet the following requirements:

• Master's Degree or Bachelor's Degree with 24 semester hours in the teaching field or a related field.
• 10 years of work experience in the field to be taught

When are you available for an interview?

Experience

Number of years of work experience

Check all degrees received:

• BS/BA
• MS/MA
• Ed.Spec.
• Doctorate

Education (Attach official transcripts)

Type of School	Institution	Location	Major(s)	Degree	Years Attended
High School
College
College
Graduate School
Other

Previous teaching experience if applicable (begin with most recent)

Name/Location of School	Grades/Subject	Dates	Reason for Leaving

Work experience other than teaching (begin with most recent)

Name/Location of Company	Type of Business	Dates	Reason for Leaving

Military Experience

Branch Rank Date of beginning of active service Date of separation Number of months of active duty

Professional Honors/Awards

Professional/Civic Organizations to which you belong

References

Name	Address	Position	Phone Number

Please describe your training and experience with technology

In what areas do you feel you have particular strengths?

In what areas do you need to further develop your knowledge and/or skills?

Please provide any additional information you desire that will afford an additional understanding of your qualifications, your goals, objectives, philosophy, and other background facts of special interest.

General Information required to apply for an adjunct teaching license

Have you ever had a teaching contract in Tennessee? If yes, cite school system(s) and date(s) Have you ever been refused tenure or a continuing contract? If yes, why? Have you ever breached a contract with another school system? If yes, why? Have you ever had a teaching/professional certificate or license revoked or suspended? If yes, why?

The following information is required by TCA §49-5-406(a)(1). Knowingly falsifying information required by TCA §49-5-406(a)(1) shall be sufficient grounds for shall constitute a Class A misdemeanor, which must be reported to the District Attorney General for prosecution.

Have you been convicted of a misdemeanor or a felony in any state? If yes, why?

(You are not required to disclose parking or moving traffic violation if the maximum sanction provided by law for such violation does not include a period of confinement.)

Have you ever been dismissed from a teaching position? If yes, fully explain the details.

Note: The employer's non-renewal of a yearly contract need not be indicated unless the non-renewal was for improper or unprofessional conduct, inefficient service, neglect of duty, incompetence, or insubordination as the same are defined in Section §49-5-501 of the Tennessee Code.)

I understand that misrepresentation of any of these certifications may subject me to the penalties prescribed in Section §49-5-406, 4-5-407, and 4-5-411 of the Tennessee Code.

Certification

I have not been convicted of a misdemeanor or a felony in any state of the United States.

I have not been dismissed from any previous employment for improper or unprofessional conduct, inefficient service, neglect of duty, incompetence, or insubordination.

I am a citizen of the United States, or have complied with the Immigration Reform and Control Act of 1986.

I do not have any contagious or communicable disease that may endanger the health of school children.

I understand that misrepresentation of any of the above statements will exclude me from participation in the Distinguished Professionals Education Institute.

Permission and authorization is hereby granted for DPEI's duly authorized representative to investigate, question, and obtain verbal and/or written records from references given, prior employers, or any other agency who may have knowledge of my qualifications and character; further, I have any and all claims which may arise against DPEI for the release of reference information. My signature below authorizes DPEI to conduct a background investigation and authorizes release of information in connection with my participation in the Distinguished Professionals in Schools Program.

Thsi investigation will include a criminal history records check conducted by the Tennessee Bureau of Investigation pursuant to Tennessee Code Annotated &Sect;49-5-413 as well as previous employers and educational institutions, personal references, and other appropriate sources. I waive my right of access to any such information, and without limitation hereby release DPEI and the reference source from any liability in connection with its release or use.

Furthermore, I certify that I have made true, correct, and complete answers and statements on this declaration in the knowledge that they may be relied upon in considering my participation in the DPEI. I understand that any omission or false answer or statement on this declaration or any supplement to it will be sufficient grounds for precluding my participation in the program.

Signed Date

Submit

The Distinguished Professionals Education Institute does not discriminate on the basis of race, sex, color, religion, national origin, age or veteran status in the educational programs and activities it operates, pursuant to Title IX of the Educational Amendment of 1972; Public Law 92-318,Section 504 of the Rehabilitation Act of 1973; Public Law 92-112; and Title VI of the Civil Rights Act of 1964.

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