REGION 14 ESC ALTERNATIVE CERTIFICATION PROGRAM
ASSOCIATE’S DEGREE
APPLICATION FORM
Date of Application: _____________________________
NAME __________________________________________________________
Last
First
Middle
_________________________________
Name you prefer to be called
MAIDEN NAME: __________________________________________________
Address ____________________________________________ City/State ______________ Zip _________
Phone ____________________ Daytime Phone ___________________ Cell # _______________________
SS# __________________________
D.L. # _______________________ E-mail _________________________
Certification Area of Interest:
ASSOCIATE’S DEGREE
High School /Colleges/Universities. List below all institutions of higher education which you have attended,
beginning with the most recent and list them in order of attendance.
PLEASE ATTACH OFFICIAL TRANSCRIPTS FROM
ALL HIGH SCHOOL / COLLEGES / UNIVERSITIES ATTENDED.
INSTITUTIONS
DATES
ATTENDED
DEGREE
MAJOR / MINOR
GENERAL INFORMATION:
Have you ever been convicted of a felony? ____YES ____NO
Language other than English?
____YES ____NO
If yes, language _________________________________
Citizen of USA?
____YES ____NO
GREEN CARD # ________________________________
Are you presently in the Military OR have you ever been in the Military? ____YES
____NO
If yes - Branch of Service and Rank _____________________________________________________________
High School attended and State __________________________________
Year of Graduation _____________________
College / University attended and State _____________________________
Have you ever been a paraprofessional in the public schools of Texas?
____YES
____NO
If Yes - Where and When _____________________________________________________________________
Are you a current paraprofessional in the public schools of Texas? ____ YES (If so, where) _________________
_____ NO
If Yes - Where and When _____________________________________________________________________
EMPLOYMENT
List below your full time work experience. Begin with your most recent or present employer.
EMPLOYER (Name, Address, Phone #)
DATES
SUPERVISOR
RESPONSIBILITIES
Name
Address
Phone #
Name
Address
Phone #
Name
Address
Phone #
Name
Address
Phone #
Name
Address
Phone #
ARE YOU PRESENTLY EMPLOYED?
______ YES
______NO
______ I authorize Region 14 ESC personnel who are responsible for considering me as an intern to contact any or all of the
employers that I have listed above. (Please initial in the space provided)
REFERENCES
List at least 3 references with addresses, zip codes and telephone numbers (no relatives)
1. ______________________________ __________________________________ __________________
Name
Address
E-Mail
___________
Phone #
2. ______________________________ ___________________________________ _________________
Name
Address
E-Mail
___________
Phone #
3. _______________________________ ___________________________________ __________________
Name
Address
E-Mail
___________
Phone#
(It is the applicant's responsibility to follow up and see that the persons you listed agree to offering a recommendation. Selection for interview will
only be scheduled upon receipt of all 3 reference forms. We will mail the reference forms to the person you listed, and the person giving the
reference will need to return it in the self-addressed, stamped envelope that will be included.)
What special skills or knowledge will you bring with you to the education profession?
As a educational assistant, how would you make a contribution to the students of Region 14?
How would you want your students to view you?
How would you help students experience success?
What experiences have you had in working with students?
Describe any work or volunteer experience you have had in which you were directly involved with
children or youth.
What are your personal goals and aspirations?
EQUAL OPPORTUNITY POLICY
Education Service Center Region 14 does not discriminate on the basis of race, religion, sex, age, national origin, marital or
veteran status, or handicap in admission or access to, or treatment or employment in its programs and activities in compliance with
applicable federal and state laws.