Nishimachi International School
2-14-7 Moto Azabu, Minato-ku, Tokyo 106-0046 Japan
Phone: +81-(0)3-3451-5520 Fax: +81-(0)3 3465-0197
employment@nishimachi.ac.jp

CHILD PROTECTION
Aligned with the recommendations of the International Task Force on Child Protection, we hold ourselves toa high standard of effective recruiting practices with specific attention to child protection. All international
applicants for positions at Nishimachi are asked to provide/verify appropriate "child protection" or ‘working
with children” certification as part of their application.

EMPLOYMENT APPLICATION
Please type or print. This form must be accompanied by: Application Letter, Resume,
Placement File, Transcripts, Credential(s), and photograph.

1. PERSONAL ================================================
Name: _____________________________________________________________(Last)(First)(Middle)Photo
Other names used now or the past, if applicable: ____________________________
Date of Birth: _______________ Gender: _______ Marital Status: _____________
Current Address: ______________________________________________________
Email: _______________________________________________
Nationality:_______________ Passport No.:

Phone: _____________________________________________

Visa status in Japan: _______________

Home Country of Residence: ____________________________________
Home Country of Residence Address:__________________________________________________________

2. COLLEGE OR UNIVERSITY EDUCATION ===============================================(Fill this section if information is not included in your resume.)
Name of each institution attended

Attended
From / To

Qualification

Subjects

3. REGISTRATION CERTIFICATE NOW HELD =============================================Country/state/region of registration certification issued: ______________________________________________
Areas of certification:____________________________________ Expiration Date: ____________________

Page 1

October 2016

4. PROFESSIONAL EXPERIENCE RELEVANT TO THIS APPLICATION =========================(Fill this section if information is not included in your resume. List last position first, and indicate type, e.g. classteacher, substitute, or student teaching.)
Name of School

Grades orSubjectsDates
FromMo / YrToMo / YrAddress (including country orregion)

Reasons forleaving

Further contract
offered?

Total number of years in education: _______________
Explain gaps in your teaching history, if applicable.: __________________________________________________

5. PERSONAL RECORD ==============================================================
a. Has your teaching credential ever been suspended or revoked?
YesNob. Have you ever been dismissed, or asked to resign, from any teaching position? Yes
Noc. Have you ever been convicted of any crime other than a minor traffic violation? Yes
Nod. Do you have any health problems?
Yes
NoFor each question answered “yes,” explain circumstances fully in writing and attach to application.

6. PROFESSIONAL AND PERSONAL REFERENCES =======================================
Include one from school leaders, who have knowledge of your teaching or administrative experience. (Fromyour current and previous 2 locations)
NamePosition

Address

Phone/Email7. LIVING ABROAD =================================================================
a. Have you ever lived abroad? Where? Why? _______________________________________________• Total number of years living outside of your country of residence: _____________
b. Are you limited as to the number of years you can stay abroad?

Yes

Noc. Will you be on leave of absence from your school district?

Yes

NoHow long? _____ATTACH ADDITIONAL RELEVANT INFORMATION, E.G., YOUR EDUCATIONAL PHILOSOPHY,RECOMMENDATIONS, COPIES OF CERTIFICATION.
The candidate makes a declaration of full disclosure and acknowledges that any agreement of employment or
subsequent employment may be terminated immediately for misrepresentation.
I HEREBY CERTIFY that all statements made here are true and correct to the best of my knowledge and authorize
investigation of all statements herein recorded. I give Nishimachi International School permission to contact
anyone related to my previous employment and release from all liability persons and organizations reporting
information.
__________________________________________________
Signature of Applicant
Page 2_________________________
Date
October 2016