===== PAGE 1 ===== # Kentucky State University School of Education Admission to Teacher Education Program (TEP) Application (Please print) (Please print)

Candidate: _____ Last _____ First _____ Middle _____ Maiden _____ Date: _____
Local Address: _____				Tel.: _____
	Street _____ City _____ State _____ Zip Code _____
Permanent Address: _____				Tel.: _____
	Street _____ City _____ State _____ Zip Code _____
E-mail Address: _____
KSU Student ID#: _____ Date of Birth: ____/____/____			Gender: _____
Ethnicity (Check one): ☐ Non-resident Alien ☐ Black, not Hispanic Origin ☐ American Indian or Alaskan Native ☐ Asian/Pacific Islander ☐ Hispanic ☐ White, not Hispanic
Classification (check all that apply):
☐ Freshman ☐ Sophomore ☐ Junior ☐ Senior ☐ Full-Time ☐ Part-Time
Major Area: _____ Advisor: _____
Grade Point Average 2.75 OR 3.0 in last 30 hours: _____ Credit Hours completed: _____ (min. 45)
Semester/Year of Admission to KSU: _____ Estimated Semester and Year of Graduation: _____
Letter Grade Achieved (C or better):		ENG 101 ___; ENG 102 ___; EDU 202 _____ AND EDU 203 _____ OR
		IECE Majors:: CDF 203 _____ AND CDF 204 _____ OR
		MUSIC Education Majors: EDU 202 _____ AND MUE 203 _____

I hereby apply to the Kentucky State University Teacher Education Committee for admission to the TEP and provide evidence that I have achieved each of the following criteria for admission to the TEP: ☐ Test Score requirement for admission to TEP: Core Academic Skills for Educators Test (CORE) Minimum Score Requirement: Reading (min. 156); Writing (min. 162); Math (min. 150). Provide copy to the School of Education office. Completed Assessment of Professional Dispositions, Values, & Behaviors form (1 filled out by you, and 2 others as indicated on form). 25 field experience hours documented in KFETS and copies of field verification forms submitted to SOE. □ Autobiographical Sketch submitted with application. Successful completion of TEP interview, scheduled by School of Education office. I authorize the University to submit confidential credentials to the Teacher Education Committee for evaluation to determine my compliance with Kentucky State University Standards and regulations for admission to the TEP. I understand that if I am admitted to the TEP, it is my responsibility to maintain credentials that are in compliance with University and Kentucky standards and regulations; and if I plan to teach in a state other than Kentucky, I also have to be in compliance with that state's standards and regulations. Furthermore, I certify that answers submitted are true and accurate to the best of my knowledge, for falsified statements on this application or other documents, unsatisfactory academic progress, failure to maintain appropriate credentials, or disciplinary action by the university against me, shall be considered sufficient cause for the Teacher Education Committee to expel me from the TEP. Signature: ___ Date:_____