89 EDUCATIONAL BACKGROUND 1 Federal Privacy Act [5 U.S.C.§552A NOTE] Statement. Authority for requesting social security account numbers: Public School Code of 1949 [24 P.S. § 12-1212, 24 P.S. §1224] Principal Purpose: To verify certification. Other Purposes: Identification and collection of criminal/disciplinary records for certified educators. Disclosure: Mandatory. Failure to provide the Social Security Number will result in an applicant not being considered for employment. HIGH SCHOOL COLLEGE/UNIVERSITY COLLEGE/UNIVERSITY GRADUATE STUDY GRADUATE STUDY SCHOOL OR INSTITUTION LOCATION MAJOR/ MINOR DIPLOMAS, DEGREES OR CREDITS EARNED GRADE POINT AVERAGE (GPA) EXPERIENCE (PRESENT OR MOST RECENT FIRST) DATES FROM TO DATES FROM TO DATES FROM TO Name of Employer Name of Employer Name of Employer (Area Code) Telephone (Area Code) Telephone (Area Code) Telephone Your Title Your Title Your Title Name & Title of Supervisor Name & Title of Supervisor Name & Title of Supervisor Work Performed Work Performed Work Performed Reason for Leaving Reason for Leaving Reason for Leaving Final Yearly Salary Final Yearly Salary Final Yearly Salary Address Address Address Please list activities that you are qualified to supervise or coach:
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