Instructional Specialist Application

Instructional Specialist Application

Personal Information

Prefix*

Mr.

Ms.

Mx.

First Name*

Middle Name

Last Name*

Date of Birth*

Mailing Address

Address*

City*

State*

Select

Zip Code*

Contact Information

Phone Number*

Phone

Email*

Language Skills

Are you bilingual?*

Select

What is your Spanish proficiency level?*

Select or enter value

Please list any additional languages you speak.

Work Eligibility

Are you a US citizen?*

Yes

Are you authorized to work in the United States?*

Yes

Have you ever worked for Yancy Life in the past?*

Yes

If so, when?*

Have you ever been convicted of a felony?*

Yes

If yes, please explain*

Background Information

Have you been fingerprinted in the last year?*

Yes

Do you still have access to your UEID number?*

Your Universal Enrollment ID number is typically ten characters beginning with "UZTX-". It is normally located in your appointment confirmation email or on the receipt provided at the time of your fingerprinting appointment.

Yes

UEID Number*

Educational History

High School*

Graduated?*

Yes

College*

Graduated?*

Yes

Degree:*

Please list any other applicable certifications or educational background:

References

Please list three professional references:

First Reference:*

First Reference Phone Number:*

Phone

Second Reference:*

Second Reference Phone Number:*

Phone

Third Reference:

Third Reference Phone Number:

Phone

File Upload*

Please complete and attach the following documents:

W9: [W9 Blank]

Current Resume

Drag and drop files here or

By checking this box, you are giving A Yancy Life permission to communicate with you by email, phone, and text message (also known as SMS). All communications will be related to your contracted services, notifications of service changes, and requests for service-related actions.

Authorization to contact via email/SMS*

If this application leads to contracted services, I understand that false or misleading information in my application or interview may result in the termination of contract with cause.

I certify that my answers are true and complete to the best of my knowledge.*

I am signing this document electronically by selecting the “I agree” button and typing my name below. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. By selecting “I agree” using any device, means, or action, I consent to this document's terms and conditions. I further agree that my signature on this document is as valid as if I signed the document in writing. I am also confirming that I am authorized to enter into this Agreement.

I agree*

Signature:*

Type your full name below:

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