Candidate: ___

Last First Middle Maiden Date: _____

Date:

Local Address: ___

t City State Z Tel.: _____

Street

State Zip Code

Tel.:

Permanent Address: ___

Tel.:

Permanent Address: ___ Street City State Zip Code Tel.: ___

E-mail Address: ___

KSU Student ID#: ___ Date of Birth: ___ / ___ / ___ Gender: ___

Ethnicity (Check one): ☐ Non-resident Alien Black, not Hispanic Origin

Non-resident Alien

Black, not Hispanic Origin □ Hispanic

Hispanic

□ Asian/Pacific Islander

☐ American Indian or Alaskan Native

White, not Hispanic

Classification (check all that apply):

☐ Freshman ☐ Sophomore ☐ Junior

☐ Senior ☐ Full-Time ☐ Part-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

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 EPP and provide evidence that I have achieved each of the following criteria for admission:

Test Score requirement for admission to EPP: Core Academic Skills for Educators Test (CC) Minimum Score Requirement: Reading (min. 156); Writing (min. 162); Math (min. 150). Provide copy to the School of Education office.

Three Completed Assessment of Professional Dispositions, Values, & Behaviors form (1 filled out by you and 2 others)

25 field experience hours and proof of field hours submitted to SEHD.

Autobiographical Sketch submitted with application.

Successful completion of EPP 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 EPP. I understand that if I am admitted to the EPP, 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 EPP.

Signature: _____ Date: _____

Date: ___