JTR Prospect Form Survey

1.	Last Name:*

2.	First Name:*

3.	Preferred First Name/Nickname:

4.	Email Address:*

5.	Current City:*

6.	State:*

7.	Zip:*

8.	Phone number:*

9.	Gender*
	--Please Select--FemaleMaleNon-binaryPrefer not to disclose

10.	Race/Ethnicity*
	African American/African/Black    Asian American    Hispanic/Latino/a    Native American/Alaska Native    Native Hawaiian/Pacific Islander    White    Prefer not to disclose    Other, please specify

11.	In 120 characters or less, give one reason why you are interested in learning how to teach in an urban, high-needs school:*

12.	Please indicate your 1st intended certification area:*
	--Please Select--Elementary Education K-6General Science 5-9Mathematics 5-9Biology 6-12Chemistry 6-12Earth-Space Science 6-12Physics 6-12

13.	Please indicate your 2nd intended certification area (Track 1 candidates only):
	--None--General Science 5-9Mathematics 5-9Biology 6-12Chemistry 6-12Earth-Space Science 6-12Physics 6-12

14.	Program year for which you intend to apply:*
	--Please Select--2017-18 (JTR Cohort 4)2018-19 (JTR Cohort 5)2019-20 (JTR Cohort 6)Undecided

15.	Please indicate whether you are a current or former:*
	Teacher, substitute teacher, staff member, or registered volunteer in Duval County Public Schools    City Year Corps Member    AmeriCorps Member    None of the above    Other, please specify

16.	Undergraduate University:*

17.	Undergraduate Degree:*
	--Please Select--B.A.B.S.Degree in progress

18.	Major:*

19.	Minor:*

20.	G.P.A.:*

21.	Date/expected date of graduation:*

22.	Graduate University (if applicable):

23.	Graduate degree concentration (if applicable):

24.	Graduate degree G.P.A. (if applicable):

25.	Date/anticipated date of graduate degree completion (if applicable):

26.	If you have taken the Florida Teacher Certification General Knowledge Exam, please indicate your score:*
	--Please Select--PassFailHaven't Taken

27.	If you have taken the Graduate Record Examination (GRE) General Test within the past 5 years, please indicate your scores and date taken:
	Verbal   Quantitative   Writing   Date of test Test Scores

28.	If you have taken the Graduate Record Examination (GRE) SUBJECT Test within the past 5 years, please indicate your scores and date taken:
	Biochemistry, Cell and Molecular Biology   Biology   Chemistry   Mathematics   Physics   Date of test Test Scores

29.	How did you hear about JTR?*
	--Please Select--Email from a JTR RecruiterCareer Fair BoothOnline Job Listing (Craigslist, Indeed, etc.)University adviser/faculty memberRadio/print adWord of MouthSocial MediaOther