Consultant Application

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1 Consultant Application Education Service Center Region W. Loop 340 Waco, Texas The Education Service Center Region 12 does not discriminate on the basis of race, color, national origin, sex, religion, age, disability, or genetic information in its programs, activities, or hiring practices. Auxiliary aids and services are available upon request to individuals with disabilities. Inquiries regarding the Title IX policies should be directed to the Office of Human Resources at ESC Region 12, 2101 W. Loop 340, Waco, TX or (254) FULL NAME: Last First Middle Street City State Zip Code Home Telephone # Cell Phone # Work Telephone # Address Other name(s) that may appear on records: (Used for certification, references, and criminal history records checks) you would be available Highest degree held: Bachelors Masters Doctorate Full-time teaching experience years Full-time administrative experience years Have you ever been employed with ESC Region 12? Yes No If yes, date of employment: Position held: Are you related to any current or former ESC Region 12 employee(s)? Yes No If yes, give employee(s) name and how you are related: Are you related to any member of the ESC Region 12 Board of Directors? Yes No If yes, give the Board Member s name and how you are related:

2 Colleges and Universities Attended EDUCATION * City State From To Major Minor Degree Received Conferred High School Attended of High School Graduation * Official transcripts are required at the time of employment PROFESSIONAL CERTIFICATION INFORMATION Type of Certificate Certificate Number Issued Expiration Administrative Counseling Secondary Elementary Supervisory Other Certificates and/or endorsements: Specific skills or experience not covered:

3 TEACHING AND/OR OTHER EDUCATIONAL PROFESSIONAL EXPERIENCE * (Begin with the most recent experience) From To Yrs. Exp. Grade/Subject Position Name/Address of School District and Campus or Organization Reason for Leaving Name/Title Current Phone * Original service records are required at the time of employment. NON-EDUCATIONAL EXPERIENCE (Begin with most recent experience) From To Yrs. Exp. Grade/Subject Position Name/Address of Company Reason for Leaving Name/Title Current Phone

4 REFERENCES List three recent references: Superintendents, principals, or supervisors for whom you have worked, who have first-hand knowledge of your work experience. Name Position Complete Address (Include Zip Code) Phone AGREEMENT I hereby certify that the information I have provided to the best of my knowledge is true, accurate and complete. Any misrepresentation or omission of facts shall be sufficient cause for disqualification of the application. Furthermore, it is understood that this application and records become the property of ESC Region 12, which reserves the right to accept or reject it. I further agree to observe all rules, regulations and policies of ESC Region 12 now in force and effect or as they may change. I hereby authorize ESC Region 12 to conduct work history, references or inquiries. I verify that I have not been convicted of a felony. By returning this document by to ESC Region 12, you are authorizing your signature. Signature

5 Education Service Center Region W. Loop 340 Waco, Texas Addendum to Consultant Application Confidential ESC Region 12, upon the satisfactory clearance of an investigation of a criminal background check for felony or misdemeanor conviction, in compliance with TEC 22.08, the applicant will be considered. By completing this addendum to the consultant application with ESC Region 12, I hereby authorize all persons, schools, companies, corporations, credit bureaus and law enforcement agencies to supply to ESC Region 12 any information concerning my background in connection with considerations, and I release ESC Region 12 from any liability and responsibility arising from doing so. Full Name: Other Names Used: Last First Middle (Include maiden name) of Birth: Year Month Day Sex: Male Female Ethnicity: Black White Hispanic Asian or Pacific Island Native American Other I understand the information I am providing about age, sex, and ethnicity will not be used to determine eligibility, but will be used solely for the purpose of obtaining criminal history record information. By returning this document by to ESC Region 12, you are authorizing your signature. Signature

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