Application for Stanley BPS Teacher

Preparation Program
Note: Please type your answers or print in blue or black ink.

Name: ______________________________________________________________________________________
Current Address:
_____________________________________________________________________________________________

_____________________________________________________________________________________________

Permanent Address (if different from above):

_____________________________________________________________________________________________

_____________________________________________________________________________________________

phone:_________________________ email: _________________________________________________

How did you hear about the program?

______________________________________________________________________________

Are you applying to any other programs?

______________________________________________________________________________

I am a U.S. Citizen or otherwise authorized to work in the U.S. on an unrestricted basis.

YES NO

If applicable, please list your visa type, visa number, and expiration:
______________________________________________________

Ethnic origin (optional): __________________________________________________________

The following information will assist us in ascertaining your Alternative Licensure status with the
Colorado Department of Education; however, providing this information is optional.

Date of Birth _______ / ________ / _________________

Social Security Number __________ / ________ / __________________

In the following section you will be asked to provide contact information for your
current and past employers.

*Please attach your resume for a detailed description of your employment history.

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Last name: ___________________________________ First name: ____________________________ M.I. _____

Employment History
Please note that by indicating “yes” when asked if the Teacher Preparation Program may contact the employers
below, you agree to have these individuals serve as references for you.

Present or Most Recent Employer dates: _________________________________

Employer: ____________________________________________ phone: _________________________________

Address: ______________________________________________________________________________________

Supervisor: ________________________________________________________ May we contact? YES NO

name title

Reason(s) for leaving? ___________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Prior Employer dates: _________________________________

Employer: ____________________________________________ phone: _________________________________

Address: ______________________________________________________________________________________

Supervisor: ______________________________________________________ May we contact? YES NO

name title

Reason(s) for leaving? ___________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Prior Employer dates: _________________________________

Employer: ____________________________________________ phone: _________________________________

Address: ______________________________________________________________________________________

Supervisor: ______________________________________________________ May we contact? YES NO

name title

Reason(s) for leaving? ___________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

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Last name: ___________________________________ First name: ____________________________ M.I. _____

Education
High School
_____________________________________________________________________________________________
name address

Graduation Year: _____________________

Special honors or awards: ________________________________________________________________________

College or University

_____________________________________________________________________________
name address

Date of graduation: ___________________________ Attended from _____________ to ____________________

Degree: ____________________________________________ Major: ___________________________________

Special honors or awards: ________________________________________________________________________

Post Graduate

_____________________________________________________________________________
name address

Date of graduation: ___________________________ Attended from _____________ to ____________________

Degree: ____________________________________________ Major: ___________________________________

Special honors or awards: ________________________________________________________________________

Other Information
Professional Associations, special trainings, professional development, foreign languages:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Special interests, hobbies: ________________________________________________________________________

Travel experience: ______________________________________________________________________________

*Please attach:
1. College transcript(s)

2. Two letters of recommendation from prior and present employers, or from college
professors. Please be sure contact information is included so they may serve as
references.

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Last name: ___________________________________ First name: ____________________________ M.I. _____

Colorado Department of Education (CDE) Information

1. Do you hold a current Teacher License? Yes No Issuing State____________________

2. Have you passed the PLACE or Praxis II exam? Yes No

If yes: Date passed _________________________

Content Area (circle one): Elementary Education / Early Childhood Education

If no: I have signed up for the:

PLACE exam in (circle one) Elementary Education (01) / Early Childhood Education (02)

Praxis II exam, Elementary Education Content Knowledge (Test #0014)

3. Have you applied to the Colorado Department of Education for your One-year Alternative
Teacher License? Yes No

If yes: Date of submission ____________________________

Have you received your Statement of Eligibility (SOE)?

Yes
No, I am still waiting to hear back from the CDE.
No, I lack coursework
No, I am re-taking the PLACE/Praxis II exam
No, other reason: _______________________________________________

If no: I plan to submit my application ________________________________________

Stanley BPS Internship

1. Please rank your preferred grade levels for internship (1= most preferred, 3= least preferred)

Preschool ______ K-1-2 ______ 3-4-5 ______ 6th grade ______ no preference ______

2. I am interested in an urban public school placement. Yes No

3. I speak Spanish. Fluently Conversationally Minimally No

4. I have taken a Stanley BPS Teacher Preparation Program tour Yes No

If no: As a necessary part of the application process, I plan to take a Stanley BPS
Teacher Preparation Program tour on ______________________ .
Date

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Last name: ___________________________________ First name: ____________________________ M.I. _____

Interview Dates
Interviews are a two-day process. All intern candidates are required to attend a tour of our BP
partner schools on either Tuesday, February 15 or Tuesday, March 1 as a mandatory part
of the interview process. In addition, candidates will visit Stanley BPS to teach a sample lesson
and interview with staff members. Please indicate which of the following dates you would be able
available for an interview. Please circle all that apply.

February 16 February 18 February 28 March 2

Essay Question
Please include a typed response to the following (no more than two pages long):

Describe an experience which you feel has been significant in your development as a person
going into the field of education. What connections can you make between this experience and
your beliefs about children and education?

I hereby certify that my answers and assertations set forth in this application are true and
complete to the best of my knowledge. If I am employed, I understand that any false statements
on this application shall be considered sufficient cause for my dismissal. I hereby authorize this
company to investigate any aspect of my prior educational and employment history.

Furthermore, I understand that if I am hired, employment with this company is “at will,” which
means that either the company or I can terminate my employment for any reason not prohibited
by state or federal law.

Signature _________________________________________ Date ______________________

It is the policy of this organization to provide equal employment opportunities to all qualified
persons without regard to race, creed, color, religious beliefs, gender, sexual orientation, age,
national origin, physical handicap, or veteran status.

Have you ever been convicted of a felony? Yes No

If you answered yes, please explain:

______________________________________________________________________________

______________________________________________________________________________