Falk Laboratory School 4060 Allequippa St Pittsburgh, PA 15261 Phone: (412)-­‐624-­‐8020/Fax: (412)-­‐624-­‐1303 APPLICATION FOR SUBSTITUTE TEACHING Name: Address: Telephone: Education: Name of College/University Certification: Credential Name References: Name Email: Days Available: Degree Area of Certification Address State Issuing Phone # Valid Dates Type of Reference (Professional/Personal) Are you able to perform the essential functions of the job – with or without reasonable accommodation? If no, explain fully: NOTICE: The Falk School does not discriminate on the basis of race, color, gender, sexual orientation, national origin, disability, age, or other factors as required by law. PRE-­‐EMPLOYMENT STATEMENT: I voluntarily give The Falk School the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation, and release from all liability all persons, companies, or corporations supplying such information. I understand that any false answers or statements made by me on this application, or any supplement hitherto, or in connection with the above mentioned investigation, will be sufficient grounds for immediate discharge. Signature of Applicant: Date: