B. Did you ever receive a discharge from the Armed Forces of the United States, which was other than "Honorable?"
Answer each question by Selecting "Yes" or "No." If you answer "yes" to any question, you are required to give a full explanation of your answer in the space provided below.
C. Have you been convicted of any criminal offense in NYS or any jurisdiction outside the State? (Other than minor traffic violations)
Moral Character Determination
A. Have you ever been dismissed, resigned from, entered into a settlement agreement, or otherwise left employment to avoid investigation and/or
dismissal for alleged misconduct?
D. Do you currently have any criminal charges pending against you?
E. Have you ever had an application for a teaching credential in New York or any other jurisdiction denied?
F. Have you ever had a teaching credential issued in New York or any other jurisdiction revoked, suspended, or otherwise invalidated?
G. Have disciplinary proceedings ever been initiated against you pursuant to New York State Education Law Section 3020-a or the disciplinary
provisions of any other jurisdictions?
1. Give a full explanation for any "yes" answer indicated above. 2. Please Attach official copies of the court record(s) including disposition of the case.
No
Yes
No Yes
A.
No Yes
No
Yes
C.
No
Yes
D.
E.
No Yes
F.
No
Yes
G.
I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge. I acknowledge that any false or
misleading information, or significant omissions, may disqualify me from further consideration for employment or be considered grounds for dismissal, if investigated and/or discovered at
a later date. I authorize Washington-Saratoga-Warren-Hamilton-Essex BOCES to investigate and obtain copies of records relating to my employment history, education, and criminal
history as required by the New York State Education Department. I authorize the BOCES to investigate any other information provided in connection with this application or my
employment in all participating districts through the Washington-Saratoga-Warren-Hamilton-Essex BOCES Substitute Teacher Registry; I agree to cooperate in such investigation; I
authorize all former employers and educational institutions to provide job-related information to the BOCES, and to any of the 31 component districts; and I release former employers and
educational institutions, and the BOCES and it's districts from all liability or responsibility for supplying or requesting such information as part of such an investigation.
THE SUBSTITUTE TEACHER REGISTRY IS A SHARED PLACEMENT SERVICE OPERATED BY THE WASHINGTON-SARATOGA-WARREN-HAMILTON-ESSEX BOCES, AND AS SUCH
DOES NOT ACT AS AN EMPLOYER OF SUBSTITUTES
By Checking this Box and typing your name in the box below you acknowledge that the information is true.
Applicant's Signature Date
B.
The Washington-Saratoga-Warren-Hamilton-Essex BOCES does not discriminate in its programs and activities, including employment and admission as applicable, on the basis of actual or perceived race, color,
creed, sex, sexual orientation, national origin, religion, age, economic status, marital status, veterans' status, political affiliation, domestic victim status, use of a guide dog, hearing dog or service dog, disability, or
other classifications protected under federal or state law, and provides equal access to the Boy Scouts and other designated youth groups. The designated district compliance officers will
coordinate compliance with the nondiscrimination requirements of Title VI and Title VII of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973,
the Age Discrimination Act of 1975, the Americans with Disabilities Act of 1990, as amended, the Boy Scouts of America Equal Access Act, and the New York State Human Rights Law. The
BOCES Compliance Officer is: Turina Parker., Washington-Saratoga-Warren-Hamilton-Essex BOCES, 1153 Burgoyne Avenue, Suite 2, Fort Edward, NY 12828. phone: (518) 746-3310,
email: tuparker@wswheboces.org. Complaints may also be filed with the Office for Civil Rights, New York Office, U.S. Department of Education, 32 Old Slip, 26th Floor, New York, NY 10005- 2500, phone (646)
428-3800, fax (646) 428-3843, email:OCR.NewYork@ed.gov
WSWHE COMPLIANCE STATEMENT
