APPLICATION FORM

Fill out necessary information and mark "X" on appropriate boxes.

Name : Last Name First Name Middle Name

Gender :  Male
Birth Date : mm/dd/yyyy
 Female Passport Size
Civil Status :  Single  Separated
 Married  Widowed
Permanent Address :
Phone Number : Fax Number : Photo
Mobile Number : Email Address :
Current Position : Length of Teaching
Experience
Name of School : Phone Number :
Address of School : Fax Number :

Subject Taught :  Language  Social Studies Additional Duties:

o English o History ________________________
o Filipino o Geography ________________________
 Mathematics o Civics
o Integrated Math o Sociology
o Algebra o Economics
o Calculus o Civics
o Geometry o Religion
o Trigonometry  Values Education
 Science  Arts (____________________)
o Integrated Science Type of Art
o Physics  Music ( __________________)
o Chemistry Type of Music

o Biology  Physical Education

o Earth Science  Others ___________________
o Other ________
 Special Education

Educational Background
Name of Degree/Certificate
Institution/ Basic Education / (High School Diploma, Year Awards
Level
School Degree/ Course College, PostGraduate Graduated Received
(Masters, PhD), etc)

College

Vocational Course

Graduate Studies
Your response will give the Personnel Development Committee (PDC) an opportunity to better understand you as a teacher and
your desire to participate in the program. Please provide a clearly-written statements in order to be considered.

1. Provide a brief yet concise professional goals in relation to this exchange program. Why do you want to participate
in this exchange program?

2. Please attach a lesson that you have used in your classroom and answer the following questions: How did you
plan/design the lesson? How was the lesson received by your students and how did you assess your students' learning?

3. Give an example of an instance where you have demonstrated flexibility in interacting with someone from a different
culture.

4. Re-Entry Action Plan. What skills and experience do you hope to gain from participating in the KPTE Program?
Describe at least two ways you will share this learning to your school and/or to your colleagues.

5. Certification. I certify that I completed this application myself, that the information given in this application is
complete and accurate.

Signature of Applicant (must be hand signed) Date