Address                        

City/State/Zip              

Phone                          

Email

 General Health        Age     Marital Status

   Social Security No.    Please check this box if you are a U.S. citizen.

   Instrument(s) you own and play and teach

Do you own a car? yes no        Year, Make and Model

1) Educational Background

2) Number of students at present oldest? youngest

3) How many years have you been teaching?

4) Teaching Experience

5) Work Related Experience

6) Musical Goals for Yourself

7) Preferred Days to Schedule Lessons (2:30-8:30PM)

Please check: Mon. Tues. Wed. Thurs. Fri. Sat. (day only)

Mornings? yes no

8) Two Character References

Reference #1

Name                                       

Address                                

City/State/Zip                 

Phone                                     

Relationship                  

Reference #2

Name                                       

Address                                

City/State/Zip                 

Phone                                     

Relationship                  

9) Two Student References

Student Reference #1

Name                                       

Address                                

City/State/Zip               

Phone                                     

Years Taught       

Student Reference #2      

Name                                       

Address                                

City/State/Zip               

Phone                                     

Years Taught       

10) What three expectations do you have of your students?

11)What are your long term professional goals?

"I hereby state that the information above is accurate and true."

Date Submitted