Name: __________________________________ SS#: _________-______-_________

Work Telephone: ____________________ Home Telephone: ___________________

Best time to call at work: __________________am/pm

Best time to call at home: _________________am/pm

Home Address: ______________________________________________________________________

______________________________________________________________________

School Name: _______________________________________________________________________

School Address: _______________________________________________________________________

_______________________________________________________________________

School Fax #: ______________________ E-mail Address: __________________________

School District: _______________________________________________________________________

Type: Urban Suburban Rural

Certificate area you would like to pilot: _________________ _______________________

Age range of the students you currently teach: ___________ _________________________

Total number of years teaching: __ ____________________________________________

Number of year teaching in certificate area: _______________________________________

Education

Degree_______________________________________

Year_________________________________________

Institution______________________________________

Major_________________________________________

Minor_________________________________________

Professional Associations/Organizations__________________________________________________

Self Description



 Male Female



 African American or Black Asian American, or Pacific Islander

 Mexican, Mexican American or Chicano Native American, American Indian, or Alaskan Native

 Puerto Rican White

 Other

Do you have access to a video camera for at least one week? Yes No

Educational Testing Service
PE & DG 16-D
P.O. Box 6885,
Princeton, NJ 08543-5119
(800) 779-3339 Fax: (609) 734-5450