Kentucky State University School of Education MASTER OF ARTS IN SPECIAL EDUCATION (LBD K-12) Admission to Teacher Education Program (TEP) Application (Please, type or print)

Candidate: ___ Date: ___ Last First Middle Maiden

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 ___ American Indian or Alaskan Native

___ Asian/Pacific Islander ___ Hispanic ___ White, not Hispanic

Advisor: ___ GPA (min. 3.0): ___ Credit Hours Completed: ___ (min. 12)

Semester/Year of Admission to KSU Graduate Program: ___ Estimated Semester and Year of Graduation: ___

Teaching Status : (Check one)

___ I am currently a full-time teacher of record in an accredited public school.

I have served as full-time teacher of record in an accredited public school for three (3) of the last five (5) years.

___I have not served as a full-time teacher of record in an accredited public school.

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.

1. A minimum of 12 semester credit hours or more of course work with “C” or better and a cumulative GPA of 3.0
2. Passing Praxis I/CORE test scores: Reading (min. 156); Writing (min. 162); Math (min. 150).
3. Completed Assessment of Professional Dispositions, Values, and Behaviors form (1 filled out by you, and 2 others as indicated on form).
4. 25 field experience hours documented in KFETS and copies of field verification forms submitted to SOE.

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: _____