EPIK APPLICATION FORM FOR MARCH 2010 1/16

PLEASE NOTE: In order to be eligible for an interview, all fields in this form
must be completed fully.
Please enter “N/A” for questions that do not apply to you to show that you have read them. Please type your

answers. Do not write.

①-1 LEGAL NAME

Enter your name exactly as it appears on your passport Please
attached your
most recent
FIRST NAME MIDDLE INITIAL
head photo
here
LAST NAME

②-1 DATE OF BIRTH ②-2 AGE

YEAR MONTH DAY

③-1 GENDER ③-2 MARRIAGE ③-3 PLACE OF BIRTH

MALE FEMALE MARRIED UNMARRIED CITY (STATE/PROVINCE) COUNTRY

④-1 PRIMARY CITIZENSHIP ④-2 SECONDARY CITIZENSHIP**

CITIZENSHIP YOU WOULD USE TO TEACH IN KOREA LIST ANY OTHER CITIZENSHIP(S) YOU HOLD

** NOTE FOR KOREAN CITIZENS: Overseas Koreans with permanent residence in one of the seven (7) designated

English-speaking countries and a minimum total of 10 years of education (from grade 7 up) in that country

may also apply

⑤-1 CRIMINAL RECORD YES NO

Have you ever been charged (whether convicted or dismissed) with anything more
serious than a minor traffic offense?
NOTE: ALCOHOL OR SUBSTANCE-RELATED TRAFFIC OFFENCES ARE NOT

CONSIDERED MINOR
⑤-2 MINIMUM EDUCATIONAL REQUIREMENTS
Have you studied in one of the seven (7) designated English-speaking countries
beginning from the first year of middle school through high school and
university for a minimum total of 10 years AND do you now or will you soon hold a
Bachelors degree or its equivalent?
⑤-3 WILLINGNESS TO WORK ANYWHERE IN KOREA
Are you willing to work at a public school anywhere in Korea?

⑤-4 WILLINGNESS TO WORK AT ANY EDUCATIONAL INSTITUTION

Are you willing to work at any public educational institute (primary, secondary or
training center)?
⑤-5 SUCCESSFUL CONTRACT COMPLETION
Have you ever resigned from, or broken, any teaching contract, whether at home or
abroad?
 EPIK APPLICATION FORM FOR MARCH 2010 2/16

If yes, please explain briefly:

⑤-6 CURRENT CONTRACT STATUS
Do you currently hold a contract position in Korea? If yes, please give the exact finish
date below.

** THE MANDATORY ORIENATION WILL BEGIN IN MID-FEBRUARY 2010 M M D D Y Y Y Y

 EPIK APPLICATION FORM FOR MARCH 2010 3/16

⑥ INTERVIEW CONTACT INFORMATION

Please many contact info as possible. Please include country code and area code with phone numbers.
Available Interview Days &
Hours
Primary Phone City & Country
Secondary Phone City & Country
Skype ID Primary email
Live (MSN) Messenger ID Secondary
email
** Interviews are scheduled in Korean Standard Time (KST). Interviews are for about 30-45 minutes, and

are HELD ONLY DURING OFFICE HOURS FROM 09:30-11:00 in the morning and 13:30-16:30 KST in the

afternoon. Please list a range of available interview dates & times (e.g., M-F, 13:30-16:30 KST).

⑦-1 CURRENT ADDRESS Please enter your contact information at the time of application

HOUSE NUMBER & STREET NAME CITY STATE/PROVINCE ZIP CODE COUNTRY

PRIMARY TELEPHONE (INCL. COUNTRY CODE & AREA CODE) EMAIL

⑦-2 CURRENT AND PREVIOUS RESIDENCE(S)

Please list the dates and names of your current address and the three most recent locations where you have lived for 6

months or more in the past 10 years (you can omit addresses where you resided for a single school term). Please list

from most recent to least recent.

STATE/PROVINCE COUNTRY FROM (MM/YY) TO (MM/YY) YEAR(S) MONTH(S)

Residence listed in section ⑦-1 MM/YY MM/YY

MM/YY MM/YY

MM/YY MM/YY

MM/YY MM/YY

⑦-3 MAILING ADDRESS FOR SUCCESSFUL APPLICANTS

EPIK normally couriers contracts to

successful applicants from December to February. Please be sure to notify your application agent or the EPIK office

immediatelyof any address changes

.

YES NO
If you are invited to become an EPIK teacher, do you expect that EPIK can mail the
contract to you at the address listed in ⑦-1?**
** IF NO, PLEASE LIST YOUR EXPECTED FUTURE MAILING ADDRESS IN SECTION ⑦-5.

⑦-4 CHANGE OF ADDRESS

Please be sure to notify your application agent or the EPIK immediately
office of any changes

to your address.

M M D D Y Y Y Y
When do you expect to change your current address?
**
** IF YOU WILL CHANGE ADDRESSES, LIST YOUR EXPECTED FUTURE ADDRESS OR PERMANENT ADDRESS INFO IN ⑦-5.
 EPIK APPLICATION FORM FOR MARCH 2010 4/16

IF YOU DO NOT EXPECT TO CHANGE ADDRESSES IN THE NEXT 6 MONTHS, PLEASE ENTER “N/A”.

⑦-5 FUTURE/PERMANENT MAILING ADDRESS FOR SUCCESSFUL APPLICANTS

Please list as much detail as possible about your expected future address or permanent address.

HOUSE NUMBER & STREET NAME CITY STATE/PROVINCE ZIP CODE COUNTRY

TELEPHONE (INCL. COUNTRY CODE & AREA CODE) EMAIL

 EPIK APPLICATION FORM FOR MARCH 2010 5/16

⑧-1 EDUCATIONAL BACKGROUND

Please fill out all of the requested fields below. For elementary, middle, and high school, list only the final institution

you attended for each level. For post-secondary education, please list all of the institutions where you have obtained

credits toward your degree(s).

For institutions where you did not obtain a degree, please enter “N/A” in the fields for “degree” and “graduation date”.

NOTE: EPIK DOES NOT RECOGNIZE DEGREES OBTAINED FROM POST-SECONDARY INSTITUTIONS OUTSIDE ONE OF THE SEVEN (7) DESIGNATED

ENGLISH-SPEAKING COUNTRIES. FAILURE TO FILL OUT THIS PART ACCORDINGLY WILL NULLIFY YOUR

APPLICATION

MUST INCLUDE YOUR GPA OR CUMULATIVE MARK/GRADE/CLASS FOR TERTIARY DEGREES

EARNED
LEVEL NAME OF INSTITUTION STATE & ENROLLMENT GRADUATION Total No.
COUNTRY DATE (MM/YY) of years
FROM TO at each
(MM/YY) (MM/YY) level/
school
ELEMENTARY MM/YY MM/YY N/A
SCHOOL
MIDDLE MM/YY MM/YY N/A
SCHOOL

HIGH MM/YY MM/YY MM/YY

SCHOOL

POST MM/YY MM/YY MM/YY

SECONDARY

EDUCATION (1)

DEGREE: GPA: / MAJOR:

POST (IF APPLICABLE) MM/YY MM/YY MM/YY
SECONDARY

EDUCATION (2)

DEGREE: GPA: / MAJOR:

POST (IF APPLICABLE) MM/YY MM/YY MM/YY
SECONDARY

EDUCATION (3)

DEGREE: GPA: / MAJOR:

⑧-2 TEFL//TESOL /CELTA or TEACHER’S CERTIFICATION/LICENSE

TITLE OF CERTIFICATION ACCREDITING ISSUE DATE EXP. DATE Hours

Complete
INSTITUTION (MM/YY) (MM/YY) d
TEFL/TESOL or MM/YY MM/YY
CELTA

TEACHERS MM/YY MM/YY N/A

CERTIFICATION/
 EPIK APPLICATION FORM FOR MARCH 2010 6/16

LICENSE
**Successful applicants must provide documented proof of the number of completed hours for a TEFL or

TESOL certificate.

If the number of hours is not stated on the certificate, additional official documentations are required. A

minimum of 100 course hours is required to be potentially eligible for a higher pay level. Initially copy of

certificate copies suffice, original certificate must be shown upon arrival in Korea.

⑨-1 NON-TEACHING WORK EXPERIENCE List from the most recent employment - add more rows if

necessary.

JOB TITLE EMPLOYER COUNTRY FROM TO NUMBER OF

(MM/YY) (MM/YY) MONTHS

MM/YY MM/YY
MM/YY MM/YY
MM/YY MM/YY
 EPIK APPLICATION FORM FOR MARCH 2010 7/16

⑩-1 FULL-TIME TEACHING EXPERIENCE

Please list only PAID full-time teaching experience at an accredited educational institution. List

from the most recent paid full-time teaching experience and add more rows if necessary. IMPORTANT

NOTE: For GET Qualification Level & Pay, EPIK ONLY accepts paid full-time teaching experience coming
from one educational institution for a minimum of “one full academic year.” In order to be eligible for a

higher GET level & salary, successful applicants MUST provide Official Proof of Teaching Experience/PTE

issued by the institution in question. The PTE should be written in an official letterhead with full contact

information of the issuing institution including official signature where applicable, as well as employment

period (start and finish dates) with the month and year employed. PTE/s should clearly state “paid full-

time teaching”; PTE/s indicating less than 12 months of employment must clearly state that the teacher

was employed for “one full academic year”. PTE/s that do not subscribe to these specifications will

automatically be null and void which will result to lower GET level and pay.

NAME OF INSTITUTION COUNTRY AGE RANGE FROM TO NUMBER OF

OF STUDENTS (MM/YY) (MM/YY) MONTHS

MM/YY MM/YY
IF YOU NOW HOLD A CONTRACT POSITION, WHEN IS THE EXACT FINISH DATE OF THE CONTRACT? M M D D Y Y Y Y
MM/YY MM/YY
MM/YY MM/YY

⑩-2 REFERENCES FOR FULL-TIME TEACHING EXPERIENCE IN KOREA

If you have taught in Korea, please list the contact information for your institution(s). Contact information

must be for the main administration office, your director or supervisor. Contacts of colleagues/co-

workers are not acceptable. If you have done more than two contracts, please list the two most recent

contracts.

NAME OF INSTITUTION NAME OF OFFICE PHONE MOBILE PHONE

DIRECTOR/SUPER

⑩-3 PART-TIME , STUDENT TEACHING, or TUTORING EXPERIENCE

List from the most recent experience and add more rows if necessary. You may also include education-related volunteer

experience in this section.

NAME OF INSTITUTION COUNTRY AGE RANGE FROM TO NUMBER OF

OF STUDENTS (MM/YY) (MM/YY) MONTHS

MM/YY MM/YY
MM/YY MM/YY
MM/YY MM/YY
 EPIK APPLICATION FORM FOR MARCH 2010 8/16

⑪ -1 SALARY LEVEL
⑪-1
EPIK salary is standardized (non-negotiable) based on qualifications, teaching experience, & credentials.

Please note that only paid full-time teaching experience for a minimum of “one full academic year” makes

an applicant eligible for a higher GET level & salary. TEFL and TESOL must have at least 100 course hours

which should be proven official documentation. Details on GET Level & Pay are attached & can also be

found in our website. Please list the pay level that you CURRENTLY qualify and your expected qualification

level (based on the completion of TEFL/TESL certification and/or teaching experience) for SY2010-2011.

LEVEL 3 LEVEL 2 LEVEL 2+ LEVEL 1

(beginning (top entry
salary) level)
CURRENT QUALIFICATION
EXPECTED QUALIFICATION
 EPIK APPLICATION FORM FOR MARCH 2010 9/16

⑫ -1 PROVINCIAL PLACEMENT PREFERENCES (please read)

⑫-1
EPIK is a national program that places teachers all over Korea. EPIK tries intentionally to place successful

applicants according to provincial/metro preferences using an unbiased first-come, first-serve placement

system. However, the final provincial/metro recommendation depends on the availability of the remaining

slots at the time EPIK receives your complete required documentation. Therefore, because of the first-

come, first-serve placement assignment of education offices, applicants must ultimately be flexible

about working anywhere in Korea in case preferred placements are unavailable at the time your

completed documents are received.

PLEASE ALSO NOTE: The final acceptance/placement decision is made solely by the Provincial Office of

Education to which you have been recommended and not the National EPIK Office. Successful applicants

are unable to select specific cities within a province or specific districts within a city-province.

⑫ -2 PREFERENCE FOR PROVINCE TYPE

⑫-2
ANYWHERE PROVINCIAL PROVINCIAL
TOWN CITY
Please check the kind of province you would prefer to work in:

⑫ -3 PREFERENCE FOR PROVINCE LOCATION

⑫-3

The 15 Provincial/Metro Offices of Education that comprise the EPIK program are (‘c’ indicates a
city-province):
 Busan (c)  Ulsan (c)  Chungbuk (Chungcheongbuk-do)  Gyeongbuk (Gyeongsangbuk-do)
 Daegu (c)  Chungnam (Chungcheongnam-do)  Gyeongnam (Gyeongsangnam-do)
 Daejeon (c)  Gangwon (Gangwon-do)  Jeju (Jeju-do)
 Gwangju (c)  Jeonbuk (Jeollabuk-do)
 Incheon (c)  Jeonnam (Jeollanam-do)

FIRST SECOND THIRD FOURTH FIFTH

List your location preferences in
order:**
**Please note that applicants who successfully pass the interview will only be recommended for placement to a

province/metro upon successful submission of all the required documents based on an impartial first-come, first-

serve basis. Please also note that the final acceptance decision is made by the Provincial Office of Education and not the

National EPIK Office.

⑫ -4 PREFERENCE FOR TYPE OF EDUCATIONAL SETTING

⑫-4
PRIMARY MIDDLE HIGH SCHOOL TRAINING
SCHOOL SCHOOL INSTITUTE
In numerical order (1 being most preferred),
list which type of school best matches your
strengths:**
**Please note that as much as Education Offices place successful applicants based on the strength of

qualifications, credentials, and backgrounds, other factors such as availability of slots and priority programs
 EPIK APPLICATION FORM FOR MARCH 2010 10/16

of districts just to name a few are also considered. As such the student body and school set-up setting

cannot be guaranteed or known in advance. The proper forum and venue for this is during the EPIK

orientation.
YES NO

⑫-5 Are you aware that provincial/metro recommendations are made only after the
successful submission of all the required documents on a first-come, first-serve basis?

⑫-6 Are you aware that specific school location and student body is determined
solely by the education office and is known only during EPIK orientation?

⑫-7 Are you aware of the potential that you might work at more than one school
(hours are the same) and/or your additional school(s) could be in adjacent small
town/s?
⑫-8 Are you aware that, although the Provincial Offices of Education try intentionally
to place you as close to your school(s) as possible, you may be required to commute
up to appr. 60 min.?
 EPIK APPLICATION FORM FOR MARCH 2010 11/16

1 JOINT APPLICATION
⑬-1
(If applicable) please list other EPIK applicants you would like to live in the same province/metro. IMPORTANT NOTE:

EPIK cannot guarantee joint applicants placements in the same city/town within a province or in the same district within

a metro.

NAME M/F RELATIONSHIP

1.
2.

MARRIED COUPLES HOUSING

IMPORTANT NOTE: Couple’s housing is offered only to married couples who are both participating as EPIK teachers.

Marital status must be proved by means of identification with the same surname or a photocopy of the marriage

certificate.
YES NO

⑬-2 Are you married to the person listed in line 1 of section ⑬-1?

⑬-3 Would you like joint housing for you and your spouse listed in line 1 of section
⑬-1?

⑬ -4 DEPENDENTS** Please list any dependents that will accompany you to Korea.
⑬-4
NAME RELATIONSHIP M/F AGE NATIONALITY

**Please note that EPIK does not provide family accommodations. Therefore, please be sure to discuss your

intention to bring dependents with you to Korea with an EPIK staff member during the application

interview.

⑬ -5 EMERGENCY CONTACT Please list the contact info of someone who can be reached easily in case of
⑬-5
emergency

FIRST NAME FAMILY NAME RELATIONSHIP TO APPLICANT

HOUSE NUMBER & STREET NAME CITY STATE/PROVINCE ZIP CODE COUNTRY

HOME PHONE (INCL. COUNTRY CODE & AREA CODE) WORK PHONE (INCL. COUNTRY CODE & AREA CODE)

MOBILE PHONE (INCL. COUNTRY CODE & AREA CODE) EMAIL

 EPIK APPLICATION FORM FOR MARCH 2010 12/16

PERSONAL MEDICAL ASSESSMENT

Applicants do not require an authorized medical exam before they arrive in Korea; all successful

applicants must take a medical exam in Korea (including an HIV and TBPE drug test**) in accordance

with the requirements of the Korea Immigration Service and the EPIK program. If the results show that the

applicant is unfit to be an EPIK teacher, all costs for entry, stay, and departure will be borne by the EPIK

applicant.
** The TBPE (tetrabromophenolphthalein
(tetrabromophenolphthalein ethyl ester) is a comprehensive drug test for use of all kinds of stimulant drugs.

Sex: HEIGHT IN c WEIGHT IN KILOGRAMS: kg

CENTIMETERS: m
① When and for what reason did you last consult a
physician? (Please explain in the adjacent space)
QUESTION YES NO IF YES, PLEASE EXPLAIN
② Are OR were you HIV (AIDS) Positive?
③ Have you ever had an infectious disease that poses
a risk to public health (such as, but not limited to,
tuberculosis and other STDs)?
④ Have you ever had any of the following:
1. allergies?

2. high blood pressure?

3. diabetes?
⑤ Have you ever suffered from, or been treated for,
depression, anxiety, or any other mental or mood
disorder? (If you have received treatment, please
explain and attach an official medical report).
⑥ Have you ever been addicted to alcohol?
⑦ Have you ever abused any narcotic, stimulant,
hallucinogenic or other substance (whether legal or
prohibited)?
⑧ If necessary, are you prepared to undergo physical
tests to verify the answers given in questions ⑥
and ⑦ above?
⑨ Have you been hospitalized in the last two (2)
years?
⑩ Have you had any serious injury, ailment or
sickness in the last five (5) years?
⑪ Do you have any visual or hearing impairments?
⑫ Do you have any physical disabilities?
 EPIK APPLICATION FORM FOR MARCH 2010 13/16

⑬ Do you have any cognitive/mental disabilities?

⑭ Are you taking any prescribed medication?
⑮ Are you on a special diet?
⑯ On average, how many standard servings of alcohol do you consume
each week?

YES NO IF YES, EXPLAIN BRIEFLY

① Have you ever been charged (whether

convicted or dismissed) with more than a
minor traffic violation?**
② Have you ever had your driver’s license
suspended (even for less than 24 hours?)
③ Have you ever applied to teach at a public
school in Korea? Where did you apply?
④ Are you currently applying for other ESL
positions? In which provinces or countries?
⑤ Have you ever visited Korea before?
⑥ Do you have any Korean language skills?
⑦ Are you a vegetarian or vegan?
⑧ Are you aware that, although Korean dishes
contain a lot of vegetables, a large number
contain small amounts of meat or meat
products?
⑨ Have you ever lived or travelled abroad for 3
months or more?
⑩ Do you have any tattoos or piercings?
⑪ Are you familiar with the job description and ** Driving under the influence of
working environment for GETs described on alcohol or other substances is NOT
the EPIK website?* considered a minor offence.
⑫ Are you aware that you will be expected to
plan lessons in advance and sometimes lead
English classes?
⑬ Do you agree to notify EPIK within 48 hours if
you drop out after you have received the
Notice of Appointment?
⑭ Were you recommended to the EPIK program Full Name
by a current EPIK teacher? If yes, please list Mobile
their contact information.** phone
Email
address
Main School
 EPIK APPLICATION FORM FOR MARCH 2010 14/16

City/Province
⑮ Where did you first learn about EPIK? Personal Referral EPIK website School/Institut
e
Embassy/ Other websites Other
Consulate

** The Referral Bonus will be given only for applicants who applied directly to EPIK (not agency or consulate/embassy

applicants).

※ REQUIRED DOCUMENTS
If you successfully pass the EPIK interview, you will be required to submit all the necessary
documents to complete your application. More information about the required documents can be
found at our website and will also be emailed to you. **DOCUMENTS SUBMITTED TO EPIK WILL NOT BE

RETURNED REGARDLESS OF THE FINAL OUTCOME OF THE SELECTION PROCESS.**

The answers I have provided throughout this application are true and correct to the
best of my knowledge and I will bear full legal and financial responsibility for any
errors or falsehoods contained herein.

FIRST NAME MIDDLE INITIAL LAST NAME

M / D / YYYY
M D
SIGNATURE DATE
(ONLINE APPLICANTS MUST TYPE HERE AND SUBMIT INK SIGNATURES LATER)
 EPIK APPLICATION FORM FOR MARCH 2010 15/16

CONSENT FOR VERIFICATION

AND COLLECTION OF PERSONAL INFORMATION

FIRST NAME MIDDLE NAME LAST NAME GENDER

M F

ADDRESS (NO., ST., CITY STATE/PROVINCE ZIP CODE COUNTRY

APT.)

BIRTH DATE PLACE OF BIRTH TELEPHONE NUM BER E-MAIL

(MM-DD-YY) (COUNTRY & AREA CODE)

I hereby authorize the English Program in Korea (EPIK) under the Korean Ministry of Education,
Science & Technology to verify on my behalf the information disclosed in this application form and the
documents required by EPIK as well as collect other information deemed necessary by EPIK to
determine the applicant’s suitability from any institution, organization or individual issuing said
information and/or documentation.

FIRST NAME MIDDLE INITIAL LAST NAME

M / D / YYYY
M D
SIGNATURE DATE
(ONLINE APPLICANTS MUST TYPE HERE AND SUBMIT INK SIGNATURES LATER)

※INFORMATION OF AUTHORIZED ORGANIZATION

English Program in Korea (EPIK)
National Institute for International Education (NIIED)
Ministry of Education, Science & Technology (MEST)
In Partnership with ESL Job Network K-16

Fax +82-55-312-8547 Email jobs@iteachntravel.com

Phone +82-070.7630.8547 Website www.esljobnetworks.com

Address 43 Ihwajang-gil, Jongno-gu, Seoul, 110-810, Republic of Korea

 EPIK APPLICATION FORM FOR MARCH 2010 16/16

PERSONAL ESSAY

FIRST NAME MIDDLE INITIAL LAST NAME

※ Please write an essay below (minimum 300 words; maximum 1 page)

We are interested in your ability to succeed as an ESL teacher in a public school in
Korea. In the space below, please share with us your reasons for wanting to teach
ESL in Korea, your educational philosophy and your thoughts on
encountering/managing cultural differences.