Submit this Application for Admission, as part of your complete application packet, by February 1 for fall admission or by September 1 for spring admission. All requirements must be met by the application deadline. Admission decisions are made by the Teacher Education Committee the semester prior to the student teaching/practicum semester.

Candidate: ___ Date of application: ___

Student ID: ___ GPA: ___ Telephone number(s): ___

Preferred mailing address: ___

Undergraduate major: ___ Date of admission to TEP: ___

Remaining ESP courses (attach Student Guide Sheet): ___

If Certified: Teacher certification (date, field): ___

Student teaching (dates, district, school, classroom setting, Cooperating Teacher):

___

KTIP (dates, district, school, classroom setting, Resource Teacher): ___

Provide dates and copies to verify the following:

Praxis II exam date(s) & score(s): ___

Federal criminal history report: _____ NEA membership year: _____

Medical exam with TB test (date): _____

Signed & dated Professional Code of Ethics for Kentucky School Certified Personnel (attached): ___

Signed & dated Character and Fitness statement (attached): _____

Employer: ___

Address:

Official job title: ___

Dates of employment in this position: ___

Job responsibilities: ___

Title: _____

Supervisor: Name: _____ E-mail: _____

Telephone: _____

Revised Spring 2018