Professional Teaching Standards Board. Wyoming Educator Renewal

Transcription

1 Professional Teaching Standards Board Wyoming Educator Renewal License or Permit Renewal Application Packet This Application Packet is to apply for Renewal of a Wyoming Standard Educator License or Permit in the following areas: License Educators Administrators (Principals, Directors, and Superintendents) Related Services Personnel (School Counselor, School Psychologist, School Social Worker, School Nurse, and Speech-Language Pathologist) Permit Substitute Teacher School Nurse Head or Assistant Coach Native Language Educational Sign Language Interpreter (ESLI) Professional, Industry, and Careers (PIC) Driver s Education Submit your complete application packet to: Professional Teaching Standards Board 1920 Thomes Avenue, Suite 100 Cheyenne, WY 82002

2 Application Instructions Wyoming Educator License or Permit Renewal Attention: Expired License or Permit Holders - Applicants whose license or permit has expired (i.e. the validity date has passed) will not be eligible to apply for renewal and must apply for reinstatement. Please visit the PTSB Website Application page: to download the appropriate application for your license or permit. Tips for All Applicants Before completing your application, read all instructions carefully. In order for PTSB to better serve you by processing your application quickly and efficiently, it is critical that submitted application packets are complete and contain all supporting documentation as outlined in the instructions and on the forms. PTSB does NOT accept photocopied, faxed, or scanned applications. Application processing times vary throughout the year. Check our current processing time by clicking on the hourglass on the PTSB homepage: It is the applicant s responsibility to maintain current information (including Name, Mailing Address, Phone Number, and Address) on file with the Professional Teaching Standards Board. o To update your information please contact our office at Renewal applicants are NOT required to resubmit fingerprint cards or U.S./Wyoming Constitution Exams. All endorsements currently held on a license or permit will be automatically renewed. Application Process Step 1 Complete the Wyoming PTSB Application Form Section I APPLICANT INFORMATION (Page 6) o Complete the information as outlined. Section II LICENSING AND LEGAL INFORMATION (Pages 6 and 7) o o Please make sure you carefully read and complete pages 6 and 7 of the application. Any disclosure must be accompanied by a personal statement indicating the circumstances and other related legal documentation (if applicable) to be considered complete. (For more information regarding your personal statement, see page 6). o Failure to disclose will delay your application. This may also lead to forfeiture of your fee, denial, or cancelation your application. o If you have any questions regarding your particular circumstance(s), please contact our office at o Sign and date the application (see bottom of page 7). Section III INDIVIDUAL RENEWAL REQUIREMENTS (page 8) o Complete all boxes of this section which apply to your situation (see page 7) and gather all documentation required. Section IV ADDITIONAL STANDARD LICENSE ENDORSEMENTS [if applicable] (pages 9-11) o Applicants may add additional endorsement areas at the time they are applying to renew their Wyoming Standard Educator License (see pages 9-11). o Include all appropriate documentation including official transcripts (see page 15), the Institutional Recommendation form (see page 13), and any testing requirement results for each added endorsement with your complete application packet. o For information on adding an endorsement through work history, please see page

3 Step 2 Provide verification of renewal credits taken All Wyoming educators are required to complete professional development/renewal credits in order to renew a license or permit. The requirements for renewing your specific license or permit are listed on the reverse side of your current certificate. If you are using PTSB-approved workshop credits to renew, record of the credit(s) will already be on file with PTSB. NOTE: Contact the workshop facilitator or send in your certificate of completion showing the date, title and contact hours if the credit has not been updated in the PTSB database. If you are using university or college transcript credit to renew, include the official transcript(s) with your application or have the college registrar s office them directly to ptsbtranscripts@wyo.gov. PTSB cannot accept transcripts that are photocopied, faxed, scanned, or an electronic version sent to the applicant by the institution. Official transcripts must contain the institutions original seal in order to be considered official (see page 15). If you are renewing your coaching endorsement you must meet the 1 st Aid/CPR requirement. Step 3 Provide copies of current 1 st Aid/CPR cards [if applicable] All coaching applicants must provide current hands-on or hybrid 1 st Aid/CPR Training o Applicants must submit copies of current, valid (front and back if applicable) 1 st Aid/CPR card(s), OR an original, signed letter verifying 1 st Aid/CPR card(s) which must include: dates of the course(s), instructor s contact information, and expiration date(s) of the 1 st Aid/CPR certification(s). NOTE: Online courses are not accepted for this requirement. It must be a hands-on or a hybrid training course. Step 4 National Board Certified Applicants [if applicable] If you are a National Board Certified Teacher (NBCT) and wish to have this recognized on your license, please include a copy of your certificate verifying your NBCT status with your application packet. The notation will appear on the reverse side of your license. Three (3) PTSB-approved workshop credits are awarded to NBCTs at the time of National Board Certification and may be used toward renewal requirements. Record of these credits will be on file with our office. Step 5 Complete the Fee Payment Form (page 16) The fees may be paid by personal check, cash, money order, cashier s check, or credit card o Please make checks payable to PTSB or Professional Teaching Standards Board

4 Step 6 Submit your complete application packet to PTSB Your complete application packet should be submitted with the documents listed in the checklist below: WYOMING PTSB APPLICATION CHECKLIST (Check the appropriate box next to EACH item included) I have completed Sections I and II Legal and Licensing Information (see pages 6 and 7) I have included a personal statement and court documents [if applicable] (see pages 6 and 7) I have completed Section III Individual Renewal Requirements (see page 8) I have included the Verification of Employment form [if applicable] (see page 12) (for Native Language, Alternative/Non-Traditional/At-Risk Youth Program, or Institutional/Private Residential Facility applicants) I have included the original Institutional Recommendation form(s) complete with university seal [if applicable] (see page 13) (only if you are adding a new endorsement) I have included the Verification of Work History form [if applicable] (see page 14) I have included official transcripts from all institutions I have attended with degree(s) posted [if applicable] (see page 15) (photocopied, faxed, or scanned transcripts are not accepted) I have included my PRAXIS II or OPI scores [if applicable] I have included my Professional Development Plan (for Alternative/Non-Traditional, At-Risk Youth Program, or Institutional/Private Residential Facility applicants) I have included current copies of my 1 st Aid/CPR card(s) [if applicable] (Coaching applicants ONLY) I have included credit card information, money order, or a check payable to PTSB or Professional Teaching Standards Board (see page 16) Submit your complete application packet to: Professional Teaching Standards Board 1920 Thomes Avenue, Suite 100 Cheyenne, WY

5 Step 7 Monitor application status You may check the status of your application at any time by logging in to the PTSB website at How to check your status: Step 1: Log in to your account. If you do not already have an account, you will need to click register now and create an account. Step 2: Select Educator Section: Click Here Step 3: Select View Report of your Licensing Information Step 4: Underneath the applicant information section you will see the following: Estimated application processing times: Fingerprints During the School Year During the Summer Months NOT REQUIRED Two-to-four weeks Four-to-six weeks REQUIRED Six-to-eight weeks Eight-to-twelve weeks These processing times are just estimates; they can be shorter or longer depending on each individual situation. Help Us Avoid Processing Delays Our goal is to process your application and renew your Wyoming Standard Educator License or Permit in a timely manner. To do that, we ask that you submit your application packet with complete and accurate information. If an application is received incomplete, you will receive a 30 Day Notice notifying you of your missing requirements. If the missing items are not received within the 30 days, your application may be canceled and your fee may be forfeited

6 Wyoming PTSB Application Form This form is required for EVERY application. You must submit this form with your complete application packet or your application will not be processed. I. APPLICANT INFORMATION (INK ONLY) Social Security No. (Required) - - Legal Last Name (Required) Legal First Name (Required) MI Maiden / Other Name Mailing Address: Address Date of Birth / / City: State: Zip Code: Gender (Optional) Male Female Address: Phone: Primary: ( ) Work: ( ) Ethnicity (Optional) American Indian or Alaska Native Anglo, Caucasian, White, not of Hispanic origin Asian, Japanese, Chinese, Vietnamese, Korean, Filipino Black, African American, not of Hispanic origin Hispanic, Chicano, Cuban, Puerto Rican, Latino, Mexican American Native Hawaiian or other Pacific Islander Please verify the following information: Yes No Are you legally eligible to work in the United States? Yes No Are you now, or have you ever been, a member of the United States military? Yes No Are you currently employed as an educator in Wyoming? (Teacher, Substitute, Administrator, Related Services, or Coach) District and School: Subject(s) and Grade Level(s) (if applicable): II. LICENSING AND LEGAL INFORMATION IMPORTANT: Failure to answer any of the licensing and legal questions in a truthful and complete manner or failure to provide truthful information or supporting documents could lead to your application being cancelled and fee forfeited. Failure to answer could also lead to disciplinary action toward any PTSB license or permit you possess. All conduct must be disclosed. Even if: It happened more than 10 years ago It happened in another state, federal court, tribal, military, or jurisdiction outside the United States You did not go to court and your attorney went for you You did not go to jail or the sentence was only a fine or probation You received a certificate of rehabilitation NOTE: If your conviction was later dismissed, expunged, set aside, or the sentence was suspended, you may be required to provide court documentation verifying the final disposition. What to include in your personal statement: Detailed explanation of each question marked yes on page 7 Dates and locations Final disposition and/or what was done to resolve the situation Documentation regarding: o Disposition of arrest and/or conviction o Any investigation or discipline on a professional license Below are examples of personal statements: Acceptable: I was arrested for shoplifting in May of I was sentenced to pay restitution and received a fine of $300. I paid the restitution and fine and my case was closed. I contacted the court and was told my records are no longer available because the arrest happened over 30 years ago. The court provided me with the attached document which verifies that my records are no longer available. Applicant Signature Unacceptable: I was convicted of a DUI in April Everything has been taken care of, and my case has been closed. Applicant Signature For more information, see the Licensing and Legal FAQs at Legal Questions Found on Page 7-6 -

7 II. LICENSING AND LEGAL QUESTIONS [Required] WARNING: Answers to the following questions are required. For each question that applies to you, you must answer yes, EVEN IF you have already answered yes in a previous application. Answering yes does not lead to the automatic denial of your application. If you answer yes to any question, you must submit a signed personal statement and supporting documents (if applicable) even if you have previously submitted a statement. For more information on personal statements, see page 5 1 Yes No Have you ever had any license, permit, or certificate from ANY professional licensing authority (education, nursing, speech-language pathology, etc.) suspended, revoked, voided, canceled, denied, rescinded, rejected, and/or otherwise taken away in Wyoming, any other state, or elsewhere? 2 Yes No Is there any action or investigation pending against a license, permit, or certificate held by you from ANY professional licensing authority in Wyoming, any other state, or elsewhere? 3 Yes No Have you ever resigned, been disciplined, discharged, or asked to resign or retire from a professional position or military service because of allegations of misconduct, or is any such action pending? IMPORTANT: This includes discipline for failure or refusal to fulfill an employment contract. Have you ever been investigated, arrested, taken into custody, cited, charged, indicted, tried, pleaded guilty to, or convicted of a felony or misdemeanor, or been found to have committed a probation or parole violation? Exclude minor traffic violations such as infractions, parking tickets, and speeding tickets. 4 Yes No IMPORTANT: In responding to this question, include any pending investigation or charge. Include all cases from federal, state, local, tribal, and military tribunals. You must also include all cases that were settled or closed by a withheld judgement or through retained jurisdiction, etc., or handled through juvenile proceedings. Even if you pleaded nolo contendere (no contest) you must disclose this. DUI s or careless driving tickets stemming from a DUI are NOT considered minor traffic violations and must be reported. 5 Yes No Is there any information not disclosed by your answers concerning your background, history, experience, education, or activities which may have some bearing on your character, moral fitness or ability to hold a license, permit, or certificate in Wyoming and which should be placed at the disposal or brought to the attention of the Wyoming Professional Teaching Standards Board? BEFORE SIGNING, CHECK PAGES 6 AND 7 FOR COMPLETENESS: Personal information with correct SSN, Mailing Address, Phone Number, Address, and Date of Birth filled in on page 6 All legal questions marked yes or no on page 7 Signed, detailed personal statement attached (if applicable) Court documents (if applicable) I attest and affirm that all statements made by me on this application are true and correct to the best of my knowledge. I understand that penalties, which may include revocation, suspension, denial, or refusal to renew, will be imposed under WS and PTSB Rules & Regulations, for making any false statement(s) on this application or required documents. Applicant Printed Name Applicant Signature Date - 7 -

8 III. INDIVIDUAL RENEWAL REQUIREMENTS [Required] Please indicate which type of license or permit renewal you are applying for by checking the appropriate boxes and provide all information required in the corresponding section. I am applying to renew my Wyoming Standard Educator License Renewal period of a license is for five (5) years for a Wyoming Standard License or 10 years for a Professional License The renewal of a Wyoming Standard Educator License requires completion of a minimum of 5 renewal credits, which may be college and/or PTSBapproved workshop credits. NOTE: While no longer offered, if you currently hold a Wyoming Professional Educator License, you are required to submit 10 renewal credits and the license is valid for 10 years. Requirements: Check EACH box below to indicate that you have met the requirement. Documentation for each requirement MUST be attached if not currently on file. A minimum of five (5) renewal credits for a Standard Educator License or 10 renewal credits for a Professional License has been met by: Official College Transcript PTSB-approved workshop credits Dropping a coaching endorsement: If you do NOT wish to renew your currently-held coaching endorsement(s), indicate by marking the box below. I would like to drop my coaching endorsement(s). I am applying to renew my Wyoming Educator Permit Renewal period of permits is for five (5) years unless otherwise stated below: SUBSTITUTE TEACHER Requirements: Check EACH box below to indicate that you have met the requirement. Documentation for each requirement MUST be attached if not currently on file. A minimum of five (5) renewal credits has been met by: Official College Transcript PTSB-approved workshop credits SCHOOL NURSE/SUBSTITUTE NURSE Requirements: Check EACH box below to indicate that you have met the requirement. Documentation for each requirement MUST be attached if not currently on file. Copy of current, valid Wyoming RN license EDUCATIONAL SIGN LANGUAGE INTERPRETER Requirements: Check EACH box below to indicate that you have met the requirement. Documentation for each requirement MUST be attached if not currently on file. A minimum of five (5) renewal credits has been met by: Official College Transcript HEAD COACH PTSB-approved workshop credits Requirements: Check EACH box below to indicate that you have met the requirement. Documentation for each requirement MUST be attached if not currently on file. Copies of current, valid (front & back) of 1 st Aid/CPR cards A minimum of five (5) renewal credits has been met by: Official College Transcript PTSB-approved workshop credits NATIVE LANGUAGE - Two (2) year renewal Requirements: Check EACH box below to indicate that you have met the requirement. Documentation for each requirement MUST be attached if not currently on file. Written approval from the Tribal Council Committee Verification of Employment form (page 11) in a Native Language teaching position from the school district which has employed you PROFESSIONAL, INDUSTRY, & CAREERS (PIC) Requirements: Check EACH box below to indicate that you have met the requirement. Documentation for each requirement MUST be attached if not currently on file. Copy of each valid professional license if required by state or by federal statutes for the occupational specialty Progress Report of Plan for Continued Professional Advancement that was submitted for the initial permit A minimum of five (5) renewal credits has been met by: Official College Transcript ASSISTANT COACH PTSB-approved workshop credits Requirements: Check EACH box below to indicate that you have met the requirement. Documentation for each requirement MUST be attached if not currently on file. Copies of current, valid (front & back) of 1 st Aid/CPR cards DRIVER S EDUCATION Requirements: Check EACH box below to indicate that you have met the requirement. Documentation for each requirement MUST be attached if not currently on file. Copy of current, valid Wyoming driver s license A minimum of five (5) renewal credits has been met by: Official College Transcript PTSB-approved workshop credits A minimum of five (5) renewal credits has been met by: Official College Transcript PTSB-approved workshop credits - 8 -

9 IV. ADDITIONAL STANDARD EDUCATOR LICENSE ENDORSEMENTS [if applicable] This section is optional and ONLY APPLIES IF ADDITIONAL ENDORSEMENT AREA(S) ARE BEING ADDED to a Wyoming Standard Educator License at the time of renewal. I would like to add an endorsement through an Institutional Recommendation NOTE: Adding an endorsement through an Institutional Recommendation requires the completion of an approved program through a regionally accredited institution of higher education. Adding an endorsement in a teaching content area(s) An individual who holds a Wyoming Standard Educator License with an endorsement in specific teaching content area(s) is eligible to teach in any Wyoming school district in accordance with his or her level of preparation. List all endorsement area(s) you are applying for below. Endorsements added via Institutional Recommendation have the same validity dates as the license to which they are added. I am applying for: Requirements: Check EACH box below to indicate that you have met the requirement. Documentation for each requirement MUST be attached. Institutional Recommendation indicating completion of a teacher preparation program from a regionally accredited institution of higher education (see page 13). Official transcripts with degree(s)/endorsement area(s) listed. No photocopied, faxed, or scanned transcripts are accepted (see page 15). Praxis II scores. This is only required for Elementary Education, Early Childhood, or Social Studies Comprehensive applicants. Adding an endorsement as a School Administrator An individual who holds a Wyoming Standard Educator License with a School Administrator endorsement is eligible to serve as an administrator in any Wyoming school district in accordance with his or her level of preparation. Endorsements added via Institutional Recommendation have the same validity dates as the license to which they are added. I am applying to add an endorsement as a: District Superintendent School Principal Program Director Requirements: Check EACH box below to indicate that you have met the requirement. Documentation for each requirement MUST be attached. Institutional Recommendation indicating completion of a school administration program from a regionally accredited institution of higher education (see page 13). Official transcripts with degree(s)/endorsement area(s) listed. No photocopied, faxed, or scanned transcripts are accepted (see page 15). Adding an endorsement in a Related Services area An individual who holds a Wyoming Standard Educator License with a Related Services endorsement is eligible to serve in any Wyoming school district in the professional service area of his or her preparation. Endorsements added via Institutional Recommendation have the same validity dates as the license to which they are added. I am applying to add an endorsement as a: School Psychologist School Counselor School Social Worker School Nurse Speech-Language Pathologist Requirements: Check EACH box below to indicate that you have met the requirement. Documentation for each requirement MUST be attached. Institutional Recommendation indicating completion of a master s degree in the appropriate field checked above (see page 13). Official transcripts with degree(s)/endorsement area(s) listed. No photocopied, faxed, or scanned transcripts are accepted (see page 15). For School Nurse, a copy of current Wyoming RN license or a letter from the Board of Nursing verifying licensure. A BSN is required. I would like to add an endorsement through Work History NOTE: This form needs to be completed by EACH district you have worked for in the last six (6) years. Please exclude Substitute and Student Teaching. Adding an endorsement in a teaching content area(s) An individual who holds a Standard Educator License with an endorsement in specific teaching content area(s) is eligible to teach in any Wyoming school district in accordance with his or her level of preparation. List all endorsement area(s) you are applying for below. Endorsements added via Work History have the same validity dates as the license to which they are added. I am applying for: Requirements: Check EACH box below to indicate that you have met the requirement. Documentation for each requirement MUST be attached. Verification of Work History form (see page 14). Copies of all appropriate licenses that coincide with all dates of employment

10 IV. COACHING ENDORSEMENTS [if applicable] This section is optional and ONLY APPLIES IF AN ADDITIONAL COACHING ENDORSEMENT AREA IS BEING ADDED to a Wyoming Standard Educator License. I would like to add an endorsement for Coaching A Coaching endorsement has the same validity dates as the license to which it is added. NOTE: Applicants may only head coach in the specific sport in which they hold the specific endorsement(s). Head Coach: Assistant Coach: Please indicate the sport-specific area(s) for the Head Coaching endorsement(s) for which you are applying: Basketball Football Golf Skiing Soccer Swimming Tennis Track/Cross Country Volleyball Wrestling Please indicate the sport-specific area(s) for the Assistant Coaching endorsement(s) for which you are applying: Basketball Football Golf Skiing Soccer Swimming Tennis Track/Cross Country Volleyball Wrestling Requirements: Check the boxes below to indicate that you have met each requirement. Documentation for each requirement MUST be attached. Currently holds a valid Wyoming Standard Educator License in one (1) of the areas in Section III (see page 8) Current Hands-on or Hybrid 1 st Aid/CPR Training applicants must submit copies of current, valid (front and back if applicable) 1 st Aid/CPR card(s), OR an original, signed letter of verification in place of 1 st Aid/CPR card(s) which must include: dates of the course(s), instructor s contact information, and expiration date(s) of the 1 st Aid/CPR certification(s). This requirement has been met by (choose one): Red Cross American Heart Association Wyoming Coaching Association/Foundation Clinic American Sport Education Program (ASEP)-Hybrid ONLY National Federation of State High School Associations (NFHS)-Hybrid ONLY Care and Prevention of Athletic Injuries (equivalent to two (2) semester hours) This requirement has been met by (choose one): College Transcript Wyoming Coaching Association/Foundation Clinic Professional Development (This course must be at least 21 hours long and be conducted by a certified instructor.) Foundations of Coaching, Theory of Coaching, Fundamentals of Coaching, or Coaching Principles This requirement has been met by (choose one): College Transcript Wyoming Coaching Association/Foundation Clinic (Fundamentals of Coaching) National Federation of State High School Associations (NFHS) (Fundamentals of Coaching) American Sport Education Program (ASEP) (Coaching Principles) Applicants who wish to add a Head Coaching endorsement must meet the following additional requirement: Prior Coaching Experience or Theory of Each Specific Sport This requirement has been met by (choose one): One (1) year of successful experience in each sport checked above as a coach, verified by supervisor on official school letterhead Theory of Coaching the Specific Sport met by (choose one): College Transcript American Sport Education Program (ASEP) Wyoming Coaching Association/Foundation Clinic ATTENTION: If you did not hold a permit or license with PTSB at the time you attended the coaching clinic, you will need to contact the Executive Director of the Wyoming Coaches Association/Foundation to get certificates of completion and submit them with this application ( If you have taken course(s) you feel meet any of these requirements please submit the course information for review

11 IV. ADDITIONAL STANDARD LICENSE ENDORSEMENTS continued [if applicable] This section is optional and ONLY APPLIES IF AN ADDITIONAL ENDORSEMENT AREA IS BEING ADDED to a Wyoming Standard Educator License. I would like to add an endorsement for an Alternative/Non-Traditional School/At-Risk Youth Program An endorsement for Alternative/Non-Traditional School or At-Risk Youth Program has the same validity dates of the license to which it is added. An individual who holds this endorsement is eligible to teach in a designated program in any content area at the grade level for which he or she is endorsed. NOTE: Applicants with this endorsement are only eligible to add this endorsement at the grade level(s) they will be teaching. Secondary teachers must teach at least one (1) course within their endorsement area(s). Requirements: Check EACH box below to indicate that you have met the requirement. Documentation for each requirement MUST be attached. Currently holds a valid Wyoming Standard Educator License in one (1) of the areas in Section III (see page 8) Verification of Employment (see page 12) by a Wyoming school district offering an Alternative Education, Non-Traditional, or Atrisk Youth Program Professional Development Plan to verify your knowledge, skills, and competencies in this endorsement area using the following format: Write a 1 2 page narrative addressing your theoretical/philosophical approach to each of the following standards below including what knowledge, skills, and competencies you have to successfully apply that approach. A. The development of your knowledge and skills in affective behaviors, including goal setting, conflict resolution, communications, responsibility, and self-esteem relating to your student population B. The development of your ability to remediate curriculum and concepts to meet individual student needs C. The development of your knowledge and skills in working with behavior management specific to the student population At the end of the narrative, state or list which activities you plan to complete within the renewal period to strengthen your compliance to the standards, with the goal of becoming an expert working in your facility. I would like to add an endorsement for an Institutional/Private Residential Facility Teacher An endorsement as an Institutional/Private Residential Facility Teacher has the same validity dates of the license to which it is added. An individual who holds this endorsement is eligible to teach in any content area, at any grade level at an approved private facility. Requirements: Check EACH box below to indicate that you have met the requirement. Documentation for each requirement MUST be attached. Currently holds a valid Wyoming Standard Educator License in one (1) of the areas in Section III (see page 8) Verification of Employment (see page 12) by a Wyoming Institutional/Private School Facility Professional Development Plan to verify your knowledge, skills, and competencies in this endorsement area using the following format: Write a 1 2 page narrative addressing your theoretical/philosophical approach to each of the following standards below including what knowledge, skills, and competencies you have to successfully apply that approach. A. The development of your knowledge and competency of dealing with special education students B. The development of your knowledge and ability to implement Individualized Education Plans (IEP) C. The development of your ability to remediate curriculum and concepts to meet individual student needs D. The development of your knowledge and competency in your communication and interpersonal skills specific to the student population and agency setting E. The development of your competency in working with behavior management specific to the student population and agency setting At the end of the narrative, state or list which activities you plan to complete within the renewal period to strengthen your compliance to the standards, with the goal of becoming an expert working in your facility

12 VERIFICATION OF EMPLOYMENT (For Alternative/Non-Traditional/At-Risk, Institutional/Private Residential Facility Teacher, or Native Language Teachers Only) This form is used for one of the following endorsement/permit areas only: Adding an Alternative/Non-Traditional School/At-Risk Youth Program endorsement Adding an Institutional/Private Residential Facility Teacher endorsement Renewing a Native Language Permit Applicant Information Applicant s Legal Name (Required) Social Security No. (Required) - - Mailing Address Street: City: State: Zip: Telephone No. Address Primary: ( ) Work: ( ) This Section to Be Completed by the Employer To the Employer: The above applicant is applying to the Wyoming Professional Teaching Standards Board for an endorsement to teach in one of the scenarios below, and as a requirement for approval, proof of present employment must be verified. Please complete this section and return this form to the applicant. Please check the type of position the applicant holds: Alternative/Non-Traditional School or At-Risk Youth Program - Grade Level(s) Institutional/Private Residential Facility Teacher Native Language Teacher By signing below, the authorized district representative verifies that this applicant is currently employed in Wyoming as indicated above within the school district or institution listed. Authorized Signature Printed Name Title Company Name or School District (Include District No.) Telephone No. Mailing Address Street: City: State: Zip: I affirm that the information provided on this Verification of Employment is true and accurate to the best of my knowledge. Signature Date

13 INSTITUTIONAL RECOMMENDATION Reminder: YOU MUST INCLUDE AN OFFICIAL TRANSCRIPT THAT HAS YOUR DEGREE POSTED Section I Applicant s Legal Name (Required) Social Security No. (Required) - - Mailing Address Street: City: State: Zip: IMPORTANT! THE APPLICANT MAY NOT COMPLETE ANY PORTION OF SECTION II BELOW. Section II is to be completed ONLY by the issuing institution s official representative. Altering any information provided in Section II constitutes false representation and may be grounds for denial, suspension, or revocation of the applicant s license. Section II College Representative: Please complete this section and return the original form to the applicant The above applicant is applying for a Wyoming Standard Educator License or endorsement. Please complete the information below to verify the state-approved professional education program(s) completed by this applicant at your institution. Early Childhood Program Early Childhood, Birth to Age 8 (or grade 3) Preschool, Birth to Age 5 (excluding Kindergarten) Early Childhood Special Education, Birth to Age 5 Completion Date Elementary Program Completion Date Elementary K-6 Elementary & Middle 5-8 Please note that Wyoming does not offer a K-8 endorsement. Applicants who completed a K-8 program may be eligible for a 5-8 endorsement if ALL the following conditions are met: 1. The program was completed after The applicant completed methods coursework in all four middle level core content areas 3. The applicant completed student teaching at the middle level 4. The applicant is eligible for single-subject content endorsement(s) in your state If all of the above requirements were met by the program, mark K-6 and 5-8; otherwise, mark Elementary K-6 only. Middle/Secondary Program Middle School 5-8 Endorsement area(s) Completion Date Content areas must be specified; General Middle School is not offered. Secondary 6-12 Endorsement area(s) Science 6-12 areas must be specified; General Science is not offered. Special Education Program Completion Date Generalist Grade Level(s) Learning Disabilities Cognitive Disabilities Visual Disabilities Physical Disabilities Hearing Disabilities Emotional Disabilities K-6/K-12 Program Endorsement area(s) Completion Date Grade Level(s) School Administrator Program Completion Date District Superintendent Grade Level(s) School Principal Program Director/Coordinator/Supervisor Related Services Program School Psychologist School Counselor School Social Worker Speech-Language Pathologist Completion Date Has the applicant met all state requirements to be eligible for licensure in the above listed endorsement area(s) in your state? If you answered NO, do not sign this form; return it to the applicant with a detailed explanation. Is a test required for program completers to Yes receive an Institutional Recommendation? No Name of test: Date taken: Score required: Score received: If you know of any reason this applicant should not teach in Wyoming schools, please send a separate statement to: PTSB, 1920 Thomes Ave., Suite 100, Cheyenne, WY If the applicant is not eligible for an Institutional Recommendation OR you are not a representative of an institution of higher education, please do not sign this form. Representatives of Alternative Route Certification Programs must attach a detailed letter explaining their organization s program requirements. Printed Name: Title: Ph: ( ) College: Regionally accredited by: Signature: Date: State: Only the signature of a Dean of the College, Certification Officer, or designee can be accepted. Yes No PLACE COLLEGE SEAL HERE (Application cannot be processed without the seal)

14 Applicant Information Applicant s Legal Name (Required) VERIFICATION OF WORK HISTORY (Only required for applicants who are adding an additional endorsement) Social Security No. (Required) - - Mailing Address Street: City: State: Zip: Telephone No. Address Primary: ( ) Work: ( ) Work History List all teaching, administrative, or other educationally related experience for three (3) out of the last six (6) years. Include only full-time assignments and assignments which required you to hold licensure or certification in the assignment area. Be very specific about which subjects were taught at the middle school or secondary levels, especially in the area of Science. Wyoming does not offer a Middle School Generalist endorsement or a General Science 6-12 endorsement. Grade Levels Taught This form needs to be completed by EACH district you have worked for three (3) out of the last six (6) years. Please exclude Substitute and Student Teaching Applicable Content Area(s) Taught or Administrator Position Exact Dates of Employment EX: 6-12 Biology and Social Studies 8/10/ /20/2016 Full-Time Position Y / N Y / N Y / N Y / N Y / N Y / N District or State Accredited Private School Cheyenne District #3 Include copies of the appropriate licenses that coincide with your work history, covering all dates of employment listed above. This section to be completed by Applicant s School Administrator To the Administrator: Please review your records and verify the applicant s teaching and/or administrative experience for your district ONLY and return the form to the applicant. If you know of any reason this applicant should not teach in Wyoming schools, please send a separate statement to: PTSB 1920 Thomes Ave. Suite 100 Cheyenne, WY Authorized Signature Printed Name Title School District (Include District No.) Telephone No. Mailing Address Street: City: State: Zip: I affirm that the information provided on this Verification of Work History is true and accurate to the best of my knowledge. Signature Date

15 VERIFICATION OF REQUESTED OFFICIAL TRANSCRIPTS For more information on submitting transcripts please visit: Transcripts are required from ALL institutions attended. Applicant s Legal Name (Required) Social Security No. (Required) - - Mailing Address Street: City: State: Zip: Telephone No. Address Primary: ( ) Work: ( ) ATTENTION: If you were enrolled under a different name (first or last) while attending any of the colleges or universities listed below, make sure to indicate it below or the application process will be delayed. Official Electronic Transcripts: o Electronic transcripts must be sent to PTSB directly from the college/university. Please have electronic transcripts ed to ptsbtranscripts@wyo.gov. Official Hard Copy Paper Transcripts: o Official hard copy paper transcripts, must be included with your paper application. Please DO NOT request the transcripts to be sent to PTSB separate from your complete application. NOTE: If you submit official hard copy transcripts separate from your application packet or transcripts from ALL institutions attended are not received, your application will be considered incomplete, delaying the application process. Date Requested Hard Copy Included Electronic Requested College/University Name Maiden/Other Names While Attending EX: 01/01/2017 University of Wyoming Mickey Mouse

16 RENEWAL FEE PAYMENT FORM Make fees payable to PTSB or Professional Teaching Standards Board Fees may be paid by personal check, cash, money order, cashier s check, or credit card. Checks must be written in black or blue ink only. Please be sure the applicant s full name is written on the check. Fees Wyoming Standard Educator License Renewal (Standard 5yr), (Professional 10 yr.) NOTE: All current endorsements areas on an applicant s license will be automatically renewed at no additional charge, $200 including coaching Substitute Teacher Permit Renewal (5 yr.) $50 Head Coach Permit Renewal (5 yr.) $50 Assistant Coach Permit Renewal (5 yr.) $50 School Nurse Permit Renewal (5 yr.) $50 Professional, Industry, & Career (PIC) Permit Renewal (5 yr.) $100 Native Language Permit Renewal (2 yr.) $50 Educational Sign Language Interpreter Permit Renewal (5 yr.) $50 Driver s Education Permit Renewal (5 yr.) $50 Renewal Application Fee: $ ONE PAYMENT MAY BE SUBMITTED TO COVER ALL APPLICABLE FEES Make fees payable to PTSB or Professional Teaching Standards Board and staple check (written in black or dark blue ink) or money order here or complete credit card information below: (VISA, DISCOVER, & MASTERCARD are accepted) Applicant s Legal Name (Required) I AM MAKING PAYMENT BY CHECK, CASH, MONEY ORDER, OR CASHIER S CHECK. PTSB ID #: I AM MAKING PAYMENT BY CREDIT CARD. Cardholder Name (please print): Cardholder Contact Number: Cardholder Billing Address: Street/PO Box City State Zip THIS PAGE WILL BE SHREDDED AFTER PAYMENT HAS BEEN PROCESSED. Social Security No. (Required) - - Visa MasterCard Discover Credit Card Number: Expiration Date: CVC Code: (found on signature line, 3 to 4 digits) - Cardholder Signature Date NOTE: Submitting an incorrect fee will delay the processing of your application. Please contact our office if you have questions at **ALL FEES ARE PROCESSED IMMEDIATELY AND ARE NON-REFUNDABLE** Professional Teaching Standards Board 1920 Thomes Ave. Suite 100, Cheyenne, WY