LDOE - Professional/Certified Application

PUEBLO OF LAGUNA DEPARTMENT OF EDUCATION

• PO Box 207 Laguna, NM 87026 • (505) 552‐6008 • humanresources@lagunaed.net
Professional / Certified Application
LAST NAME*
FIRST NAME*
Middle Initial
Date of Birth*

MonthDayYear
Month/Day/Year
ETHNICITY*
POSITION APPLYING FOR*
TEACHING LICENSE NUMBER (if applicable)
EMAIL ADDRESS*
MAILING ADDRESS*

P.O. BOX / STREET ADDRESS

Street Address Line 2

CITYSTATE (Example: NM, TX, AZ)

ZIP CODE
CELL PHONE NUMBER*
DRIVER'S LICENSE NUMBER*
STATE*
TWO LETTER STATE ABBREVIATION
EXPIRATION DATE*

MonthDayYear
Driver's License Expiration
ARE YOU A VETERAN?

YESNO
SOCIAL SECURITY NUMBER*
Are you authorized to work in the U.S.?*

YESNO

EDUCATION

PROFESSIONAL/CERTIFIED APPLICATION (Continued)
List the universities you have attended

(Begin with the most recent)
Name of University
#1
DATES ATTENDED
FROM

MonthDayYear
TO

MonthDayYear
Degree Received
Name of University
#2
DATES ATTENDED
FROM

MonthDayYear
TO

MonthDayYear
Degree Received
Name of University
#3
DATES ATTENDED
FROM

MonthDayYear
TO

MonthDayYear
Degree Received
Name of University
#4
DATES ATTENDED
FROM

MonthDayYear
TO

MonthDayYear
Degree Received
Name of University
#5
DATES ATTENDED
FROM

MonthDayYear
TO

MonthDayYear
Degree Received
Name of University
#6
DATES ATTENDED
FROM

MonthDayYear
TO

MonthDayYear
Degree Received
List other teaching endorsements you possess

PAST EMPLOYMENT

PROFESSIONAL/CERTIFIED APPLICATION (Continued)
TEACHING AND OTHER EMPLOYMENT EXPERIENCE (list your most recent experience first and work back)
A. Employer/School District
Address
Position / Title / Grade or Subject
Start Date

MonthDayYear
FROM
End Date

MonthDayYear
TO
Total Years
Enter the number of years at this employer.
Immediate Supervisor's Name
Supervisor Phone Number
Reason For Leaving
B. Employer/School District
Address
Position / Title / Grade or Subject
Start Date

MonthDayYear
FROM
End Date

MonthDayYear
TO
Total Years
Enter the number of years at this employer.
Immediate Supervisor's Name
Supervisor Phone Number
Reason For Leaving
C. Employer/School District
Address
Position / Title / Grade or Subject
Start Date

MonthDayYear
FROM
End Date

MonthDayYear
TO
Total Years
Enter the number of years at this employer.
Immediate Supervisor's Name
Supervisor Phone Number
Reason For Leaving
D. Employer/School District
Address
Position / Title / Grade or Subject
Start Date

MonthDayYear
FROM
End Date

MonthDayYear
TO
Total Years
Enter the number of years at this employer.
Immediate Supervisor's Name
Supervisor Phone Number
Reason For Leaving
E. Employer/School District
Address
Position / Title / Grade or Subject
Start Date

MonthDayYear
FROM
End Date

MonthDayYear
TO
Total Years
Enter the number of years at this employer.
Immediate Supervisor's Name
Supervisor Phone Number
Reason For Leaving
If presently employed, may we contact your employer?

YesNo

PERSONAL REFERENCES

PROFESSIONAL/CERTIFIED APPLICATION (Continued)
List three (3) people who know you well.

They should be good friends, co‐workers, peers, roommates, etc. and who have known you for at least five (5) years. Do not list relatives, or anyone who is listed elsewhere on this application.
Personal Reference 1
Telephone Number
Email Address
Mailing Address
PO Box, City, State, Zip
Please list the amount of time that you have known this person:
From

MonthDayYear
To

MonthDayYear
Personal Reference 2
Telephone Number
Email Address
Mailing Address
PO Box, City, State, Zip
Please list the amount of time that you have known this person:
From

MonthDayYear
To

MonthDayYear
Personal Reference 3
Telephone Number
Email Address
Mailing Address
PO Box, City, State, Zip
Please list the amount of time that you have known this person:
From

MonthDayYear
To

MonthDayYear
Do you have relatives working for the Laguna Department of Education?

YESNO
Please list their names:

Residence

List where you have lived, beginning with the most recent and working back 5 years. All periods in the last 5 years must be accounted for in your list.
1. CURRENT Street Address & Mailing Address
House number/Street name and P.O. Box (If applicable)
Street Address

Street Address Line 2

CityState

Postal / Zip Code
Starting Date

MonthDayYear
When did you start living at this current address?
Present

MonthDayYear
2. Street Address & Mailing Address
House number/Street name and P.O. Box (If applicable)
Street Address

Street Address Line 2

CityState

Postal / Zip Code
Starting Date

MonthDayYear
When did you start living at this address?
Ending Date

MonthDayYear
When did you stop living at this address?
3. Street Address & Mailing Address
House number/Street name and P.O. Box (If applicable)
Street Address

Street Address Line 2

CityState

Postal / Zip Code
Starting Date

MonthDayYear
When did you start living at this address?
Ending Date

MonthDayYear
When did you stop living at this address?
4. Street Address & Mailing Address
House number/Street name and P.O. Box (If applicable)
Street Address

Street Address Line 2

CityState

Postal / Zip Code
Starting Date

MonthDayYear
When did you start living at this address?
Ending Date

MonthDayYear
When did you stop living at this address?
5. Street Address & Mailing Address
House number/Street name and P.O. Box (If applicable)
Street Address

Street Address Line 2

CityState

Postal / Zip Code
Starting Date

MonthDayYear
When did you start living at this address?
Ending Date

MonthDayYear
When did you stop living at this address?

Notice: The Crime Control Act of 1990, Public Law 101‐647 (codified in 42 United States Code 13041), requires that employment applications for child care positions have applicants sign a receipt of notice that a background check will be conducted as a condition of employment.

Native American Preference. Applications submitted will be shredded 6 months after application date, if not hired.

I authorize the Pueblo of Laguna Department of Education to obtain any record of criminal history with the understanding that such information held in confidence and used solely for the purpose of evaluating my application. I certify that my responses to these questions are made under the Federal penalty of perjury, which is punishable by fines or imprisonment, and that I have received notice that a criminal check will be conducted. I understand my right to challenge the accuracy and completeness of any information contained in the report. I affirm that all the information contained in this application is true and complete and that any misrepresentation, falsification or omission shall be cause for dismissal from, or refusal of employment. I hereby authorize the Pueblo of Laguna Department of Education to request any information from my previous employer(s) and I authorize any references to release such information.
You may upload supporting documents below:

Certifications / References
Cancelof
Applicant's Signature:*

Clear
Today's Date:*

MonthDayYear
Should be Empty:

PUEBLO OF LAGUNA DEPARTMENT OF EDUCATION

Professional / Certified Application

EDUCATION

PAST EMPLOYMENT

PERSONAL REFERENCES

List three (3) people who know you well.

BACKGROUND INFORMATION

Residence