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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

Employer:_____

Address: ___

Official job title:

Dates of employment: ___

Job responsibilities: ___

Supervisor

Name: _____ Job Title: _____

E-mail: _____ Telephone: _____

Job Title: ___

Telephone: ___

*****

Employer:___

Address: ___

Official job title: ___

Dates of employment: ___

Job responsibilities: ___

Supervisor

Name: _____ Job Title: _____

E-mail: _____ Telephone: _____

Job Title: ___ Job Title:

Telephone: ___

*****

Employer:_____

Address: ___

Official job title:

Dates of employment: ___

Job responsibilities: ___

Supervisor

Name: _____

E-mail: _____ Job Title: _____

Job Title:

Telephone: _____

Revised Spring 2018

Student teachers must complete one term in an elementary school and the other term in a middle school or high school. In order to assist with your own placement, please propose four options: two elementary schools, one middle school, and one high school.

School district: ___ School: ___

Accreditation/Accrediting Body: ___ School population (#): ___

School population (#): ___

Principal: _____ Telephone: _____

Principal's e-mail: ___

School district: _____

School:

Accreditation/Accrediting Body: _____ School population (#): _____

Principal: _____ Telephone: _____

Principal's e-mail: ___

School district: _____ School: _____

School:

Accreditation/Accrediting Body:

School population (#):

Principal: _____

Telephone: _____

Principal's e-mail: ___

School district: _____ School: _____

Accreditation/Accrediting Body: ___ School population (#): ___

Principal: _____ Telephone: _____

Principal's e-mail: ___

Student Teacher Applicant's Statement: I verify that the information in this application is current and accurate.

Applicant's signature: _____ Date: _____

Date: ___

Revised Spring 2018

School district:

School: ___

School address: ___

Principal: ___

Telephone: _____

School population: _____

Gender and Ethnicity (number of students)

# Females: ___ # Males: ___

White: ___ Black/African American: ___ American Indian/Alaska Native: ___

Asian: ___ Hispanic/Latino Origin: ___ Native Hawaiian/Other Pacific Islander: ___

Multiracial: ___ Students who qualify for free or reduced meals: ___

504 Plans: ___ IEPs/IFSPs: ___ GSSPs: ___ ELL: ___ Behavior Plans: ___

Grade(s): ___ Class enrollment: ___

Content area(s): ___

Gender and Ethnicity (number of students)

# Females: ___ # Males: ___

White: ___ Black/African American: ___ American Indian/Alaska Native: ___

Asian: ___ Hispanic/Latino Origin: ___ Native Hawaiian/Other Pacific Islander: ___

Multiracial: ___ Students who qualify for free or reduced meals: ___

504 Plans: ___ IEPs/IFSPs: ___ GSSPs: ___ ELL: ___ Behavior Plans: ___

Alternative Certification Applicant's statement: I verify that the information in this application is current and accurate. I further verify that I am employed full-time as a Special Education Teacher at this site.

Applicant's signature: ___

Date: ___

I verify that this applicant is employed full-time as a Special Education Teacher at this site and that he or she has my permission and support to complete his or her alternative certification practicum here, during the next academic semester (fall or spring).

Principal's signature:

Date:

Revised Spring 2018

Necessity, Function, and Conformity: KRS 161.028 requires that the Education Professional Standards Board develop a professional code of ethics. This administrative regulation establishes the code of ethics for Kentucky school certified personnel and establishes that violation of the code of ethics may be grounds for revocation or suspension of Kentucky certification for professional school personnel by the Education Professional Standards Board.

Revised Spring 2018

Section 2. Violation of this administrative regulation may result in cause to initiate proceedings for revocation or suspension of Kentucky certification as provided in KRS 161.120 and 704 KAR 20:585. (21 Ky.R. 2344; eff. 5-4-95; recodified from 704 KAR 20:680, 7-2-2002.)

Printed Name: _____

Signature: _____ Date: _____

Date:

Revised Spring 2018

Page 3

(This form must be completed with each certification application and submitted to the Education Professional Standards Board, Division of Certification, 100 Airport Road, 3rd Floor, Frankfort, KY 40601, (502) 564-4606, (888) 598-7667, or www.Kyepsb.net)

Name: ___ Social Security Number: ___

Address: ___

(City) (State) (Zip Code)

(Street)

Telephone Number: ( )

Answer each question by circling "yes" or "no." If you answer "yes" to any question, you must submit a full explanation using a separate sheet of paper.

If you have ever held, or currently hold a professional certificate, license, credential, or other document issued to you by any jurisdiction (other than Kentucky) within the United States or abroad, enclose a copy of the certificate(s) or provide the following:

State or Jurisdiction ___ Certificate Number ___

Type ___ Issue Date ___ Expiration Date ___

(Date of Review)

I affirm and declare that all information given by me on this form is true, and correct, and complete to the best of my knowledge. I understand that any misrepresentation of facts, by omission or addition, may result in the denial or revocation of my teaching certificate. Further, I understand that KRS 161.120 provides that a teaching certificate may be revoked at any time upon determination that false information was presented toward obtaining a teaching certificate.

I declare that I understand the standard for personal and professional conduct expected of a professional educator in Kentucky. I further certify that I have read and examined the CODE OF ETHICS (page 4) applicable to school personnel, understand its provisions, and agree to abide by its terms during the course of my career as a professional educator.

SIGNATURE___ DATE ___

DATE