Association for International Practical Training * Columbia, Maryland 21044
www.aipt.org * 410-997-2200

TEACHER INTEREST FORM

IMPORTANT: This is a preliminary application. If selected for an interview, you will be asked to provide additional information, such as copies of diplomas, letters of recommendation, and a copy of your passport's biographical page.

All required fields must be answered completely and in English.

Date

* Date of Application
(MM/DD/YYYY)

1. Personal Information

AS APPEARS ON PASSPORT

* Title

* Surname (family name)

* First Name

* Other name(s) (as printed on passport)

* Primary Telephone
(Include country and city codes)

Other Telephone

* E-mail Address

* Re-type E-mail Address

* Gender

Male

Female

* Marital Status

Single (unmarried)

Married

* Date of Birth
month, day, year (Example: June 1, 1985)

* City/Town of Birth

Country of Birth

State/Province of Birth

* Country of Citizenship

* Country of Permanent Legal Residence

2. Dependents

* Do you have dependents you intend to bring with you to the United States? (only your spouse and children under age 18 are eligible)

No -- skip to Section 3

Yes -- tell how many and complete section below

First Name of Dependent #1

Last Name

Relationship to you

City of birth

Country of birth

Country of citizenship

Country of legal residence

First Name of Dependent #2

Last Name

Relationship to you

City of birth

Country of birth

Country of citizenship

Country of legal residence

First Name of Dependent #3

Last Name

Relationship to you

City of birth

Country of birth

Country of citizenship

Country of legal residence

3. Address

PERMANENT ADDRESS

* Street Address

Street Address #2 (If applicable)

* City/Town

State/Province

* Country

Postal Code

CURRENT ADDRESS

* Same as above

Yes

No (complete this section)

Street Address (No P.O. boxes)

Street Address #2 (If applicable)

City/Town

State/Province

Country

Postal Code

4. Qualifications

* Years of teaching experience (must have at least 3 years to be eligible):

* Grade levels you have experience teaching:

Primary grades (K through 5)

Middle school/Junior high (grades 6 - 8)

High School (grades 9 - 12)

* Which subjects are you certified in your home country to teach?

* For each subject area, tell which course(s) you are qualified to teach (ex: If you answered "Math," indicate Algebra, Geometry, Calculus, etc.)

Do you have experience teaching any type of international curriculum?

No	Yes, I have taught (ex: International Baccalaureate):

* I am a native speaker of English

Yes

No (complete this section)

Your position will require an advanced understanding of the English language. Please answer the following relative to your comprehension of the English language:

If fluent in language(s) other than English, please list them here:

5. Desired Position

* Please indicate what type of teaching position in the United States you are requesting and are certified to teach. Note: only positions for grades Kindergarten through 12th are eligible.

Primary grades (K through 5)

Middle school/Junior high (grades 6 - 8)

High School (grades 9 - 12)

* Which subjects would you like to teach in the United States?

* For each subject area, tell which course(s) you would prefer to teach (example: If you selected "Math" from the above list, indicate Algebra, Geometry, Calculus, etc.). Please only list subjects you are certified to teach.

* Preferred program length:

6. Visa Information

* In which city is the United States Embassy/Consulate where will you apply for the J-1 visa?

* Have you previously visited the United States on a J-1 visa?

No

Yes (complete section below)

If you answered "Yes" and have visited the United States on a J-1 visa, please provide:

Date of entry into the United States
month, day, year (example: June 1, 2004)

to

Date of exit from the United States
month, day, year (example: June 25, 2004)

Name of Sponsor(s)

Purpose of Visit

* Are you currently in, or have you in the previous 24 months, visited the United States?

No

Yes (complete section below)

If you answered "Yes" and are currently in, or have visited the United States in the last 24 months, please provide:

Type of Visa Held

Purpose of Visa

Date of Entry (month/day/year)

to

Date of Exit/Date of Scheduled Exit (month/day/year)

* Have you ever been refused a visa to the United States?

No

Yes (complete section below)

If you answered "Yes" and have been refused a visa to the United States, please provide:

Type of Visa Sought

Date of Visa Refusal (month/day/year)

Reason for Refusal

7. Emergency Contact Information

Give the name and contact information of a relative or close friend in your home country who AIPT can contact in case of an emergency in which we cannot reach you.

* Title

* Surname (family name)

* Given Name(s)

* Relationship to You

* Street Address

Street Address #2 (If applicable)

* City/Town

State/Province (If applicable)

* Country

Postal Code

* Primary Telephone
(Include country and city codes)

Secondary Telephone
(Include country and city codes)

* E-mail address

8. Statement of Motivation

* REQUIRED: Explain why you have chosen to pursue this opportunity and how it reflects your personal goals and characteristics. Describe how you predict this opportunity will impact your life from a cultural and professional perspective.

The response should be no more than 150 words.

9. Resume/Curriculum Vitae

Please upload your resume/curriculum vitae, with the following guidelines in mind:

1) List only your university-level education information.
2) Be sure to include relevant work experiences and certifications.

* Upload your current resume/curriculum vitae once the guidelines have been reviewed and understood.

* How did you learn about AIPT's Teach USA program?

If you answered "other," please tell how you learned about AIPT's Teach USA:

10. Program Terms and Conditions

If you have any questions about these program conditions or other program details, it is important that you contact AIPT immediately at TeachUSA@aipt.org or 410-997-2200.

Read and check each statement below to indicate agreement. Please also sign and complete below before sending the application for consideration to AIPT.

* As an exchange visitor under AIPT sponsorship, I hereby agree to the following program terms and conditions:

* Date:

* Full name:

Note: Full name is required to process this application. If you have any questions about the above-stated program conditions or other program details, it is important you contact AIPT at TeachUSA@aipt.org.

Application Fee Payment

Complete this section only if you have been selected to teach at a U.S. school and you (not the school) will pay the program fee. Do NOT complete this section if you have NOT yet been selected by a school.

Download Here: Participant Application Payment Form

Upload your completed payment form here. All information must be correct and payment signature must be original. No electronic signatures will be accepted.

* Indicates Response Required


	Fluent	Somewhat fluent	Limited ability	No ability
Reading
Writing
Speaking
Hearing

less than 3 months	13-18 months
3-6 months	19-24 months
7-9 months	25-30 months
10-12 months	31-36 months (36 months is maximum allowed)
other