First Name:
Last Name:
e-mail:	sample-applicant@example.com
Personal Phone Number:	( ) -
Personal Address:
City:
State:	AK AL AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY Zip:

School Name:
	Do you intend to return to the same school for Fall 2016? Yes   No
School Designation:	(e.e. Title I, magnet, IB Program, STEM, year-round, etc.)
School Address:
City:
State:	AK AL AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY Zip:
School e-mail:
School Phone Number:	( ) -
Teaching Level:	Select all that apply) Middle School    High School
Current Teaching Area:	(Select all that apply if you are teaching in multiple content areas this year) Middle School Science Middle School Math Middle School Technology Education General/Physical Science Earth/Space Science Biology Chemistry Physics Environmental Science Algebra Geometry Calculus Technology Education Engineering Education Other - Please specify and include AP IB and other special classes
Years Teaching:

Highest Degree Earned:	(eg, MS in Biology)
Institution of Highest Degree Earned:
Areas of certification/licensure:
National Board Certified:	Yes No Currently working on certification

Important! Letters of recommendation should come from your principal or one of your professional colleagues. On giving us the name and email of your recommendees, we will contact them to request them to fill out a form with their reccomendation letter and other information. Please inform them that they will be receiving an email from notices@epsso.net with these instructions. Letters of recommendation are due by Tuesday, April 5, 2022.

Name:
Title:
email:
email confirm:

Program Location: North Carolina State University University of Virginia Florida International University Pennsylvania State University

Will you be avaliable June 18th to July 27th, with a break from July 2nd - 6th, to participate in the RET program? Yes  No
  If no, please explain when you will be unavaliable.

Are you a US Citizen or permanent residet of the United States or its possessions? Yes  No

Were you an RET with ASSIST last Summer? Yes  No

The following questions about gender, ethnic and racial self-identification, disability status, and veteran status are not criteria for acceptance but for Federal reporting purposes only.

Gender:	Male Female I choose not to specify
Ethnicity:	Hispanic or Latino Not Hispanic or Latino I choose not to specify
Race:	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White I choose not to specify
Disability Status:	not disabled Disabled Disabled veteran I choose not to specify
Veteran Status:	Served on active duty in the US Armed Forces, Military Reserves or National Guard Training for Reserves or National Guard Only Never served in the military I choose not to specify

I certify that all the information provided in this application is true to the best of my knowledge.