Professional Teaching Standards Board. Wyoming Educator Permit

Transcription

1 Professional Teaching Standards Board Wyoming Educator Permit Application Packet This Application Packet is for individuals Applying for an Initial or Reinstatement Wyoming Educator Permit in the following areas: Substitute Teacher, Head Coach, Assistant Coach, School Nurse Substitute School Nurse, Trade and Technical (PIC), Native Language, and One-year Internship

2 Thank you for applying for a Wyoming Educator Permit. Before completing your application, read all instructions carefully. In addition to the general information for all applicants, you will find details specific to each permit type. General Application Guidelines **Only COMPLETE application packets will be accepted by PTSB for processing. Incomplete or unsigned application packets will be returned to the applicant unprocessed.** Applying for a Wyoming Educator Permit Requirements for a Wyoming Educator Permit vary depending on the type of permit. Once you have filled out the application form, you must also ensure that you have met all additional requirements under Section III, Individual Permit Requirements. All permit types and their corresponding requirements are listed in this application packet. Important Reminders for All Applicants PTSB can NOT accept faxed applications. Processing of applications takes approximately four weeks. Please do not contact our office regarding your application prior to the fourth week. You must submit a complete application packet with all required documentation. The following must be attached or your application packet will be returned to you unprocessed. Official transcripts An Institutional Recommendation (School Nurse Applicants Only) Fingerprint cards or district verification of fingerprinting The appropriate fee It is not necessary to submit official transcripts in a separate, sealed envelope; however, they must contain the institution s original seal in order to be official. Copies cannot be accepted. When requesting official transcripts, be sure to have the issuing institution list your degree area(s) on the transcript. Transcripts that do not list the applicant s degree area(s) cannot be processed. 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. Reinstatement Applicants Reinstatement applicants must meet all of the requirements listed on their previously held Wyoming Educator Permit. A complete list of those requirements can be found on the reverse side of the applicant s previously issued Permit. In addition, all reinstatement applicants (except assistant coach) must complete five semester hours of either PTSBapproved workshop credits or coursework from an accredited institution of higher education

3 Out-of-State Applicants In order to avoid processing delays, out-of-state applicants should submit any/all of the documentation listed below which applies to them. Depending on his or her experience and education, an out-of-state applicant may also be required to complete additional requirements in order to obtain a Wyoming Educator Permit. Documentation for out-of-state applicants: Copies of ALL teaching licenses or certificates held within the last six years. The Verification of Work History form found under the Supplemental Forms section of this application packet. This form must be filled out completely and accurately and must be signed by the applicant s present or most recent school administrator or board chair. Verification of all additional requirements under the permit type for which you are applying (Section III)

4 Application Instructions Instructions for Completing the PTSB Application Packet for a Wyoming Educator Permit Avoid Processing Delays Failure to complete the application packet completely and accurately will result in application processing delays incomplete applications WILL BE RETURNED unprocessed. Application Process Step One Complete the application form Read ALL sections of the application packet carefully before completing. Complete the Application Form and the Individual Permit Requirements sections of the application and gather any documentation required in these sections. Sign and date the application. Step Two Complete Fingerprint Cards Fingerprint cards may be obtained at any Wyoming school district administrative office or from PTSB. To obtain cards from this office you may contact us at , or ptsbtemp@state.wy.us to request cards. Cards will be sent to the address you provide. Carefully follow the instructions contained in the application packet for fingerprinting. Complete the identification information on the fingerprint cards, and then contact a local law enforcement agency for fingerprinting (fingerprint cards may be completed through any law enforcement agency). Include fingerprint cards in your complete application packet both the orange (signed and notarized) and blue cards must be included. If you are currently employed in a Wyoming school district and have been previously fingerprinted in Wyoming by your district, you may not be required to be re-fingerprinted for this application. We will accept a letter on official letterhead from your school district verifying that you work for that school district and that they have fingerprinted you in Wyoming within the last year. Include the letter of verification in your complete application packet. Step Three Provide Verification of Coursework IMPORTANT! When requesting copies of documentation from an issuing institution, be sure that you have that documentation sent or issued directly to you. Once you have all original documentation compiled together in your complete application packet, forward the entire packet to PTSB. Request academic transcripts from ALL colleges and universities where coursework was completed. Be sure to have the transcripts sent directly to you. Include all transcripts in your complete application packet. If you are applying for School Nurse, obtain an Institutional Recommendation. Include it in your complete application packet. Applicants are required to demonstrate knowledge of the U.S. Constitution and the Wyoming Constitution either through coursework or by examination. Include exam results or a transcript of coursework in your complete application packet

5 Step Four Provide appropriate application fees: Verify the correct fee amount for the specific permit for which you are applying. Fee amounts are listed on the Fees form. Verify whether or not you will need to be fingerprinted and include the $50 fingerprint processing fee if applicable. Complete the Fees form and include it in your complete application packet. Personal checks, money orders, cashiers checks, and credit card payments are accepted. Step Five Complete the Application Checklist The Application Checklist located on page five (5) is REQUIRED as part of the complete application packet. Check the appropriate box for EACH item on the checklist. Attach the Checklist to the top of your application packet. Step Six Submit your complete application packet to PTSB: Your complete application packet should be submitted with all of the following documents, in the order listed below: Application Checklist, with each item on the list appropriately checked off Application Fees Form, with fee attached Application Form Individual Permit Requirements (section III) for the specific permit for which you are applying, with all requirements in the section checked off, and all additional documentation attached Additional documentation (if applicable to your specific permit type): Fingerprint Cards Institutional Recommendation (School Nurse Applicants Only) Academic Transcripts Verification of Employment Verification of Work History Return your complete application packet to: Professional Teaching Standards Board 1920 Thomes Avenue, Suite 400, Cheyenne, WY Step Seven Monitor application processing and application status Three to four days after submitting your complete application packet, you will receive a courtesy green card in the mail notifying you that your application was received by PTSB and is being processed. Allow up to four weeks from the time you receive your green card for processing of your application. Incomplete applications will not be processed and will be returned to the applicant. If you do not receive your permit within four weeks, please contact PTSB for more information or a status update

6 Application Checklist Wyoming Educator Permit Completion of the Checklist below is REQUIRED for all applicants. Please double check to ensure that you have attached all applicable documentation and marked the corresponding check box. The checklist should be attached to the front of your COMPLETE application packet. Important Reminder: When requesting copies of documentation from an issuing institution, be sure that you have that documentation sent/issued directly to you. Once you have all original documentation compiled together in your complete application packet, forward the entire packet to PTSB. PTSB Permit Application Checklist Please Note: Not all items on the checklist may be necessary for the permit for which you are applying. If the item is not applicable to your permit, mark N/A. In addition, some applicants may already have documentation on file at PTSB. If documentation is already on file, mark the checklist accordingly. All other documentation must be attached and marked Included in this submission. Application Packets for an Initial or Reinstatement Educator Permit must include: (Check the appropriate box under EACH item below) Documentation Type Included in this submission Already on file at PTSB This Checklist attached to the front of your complete application packet Application Form Individual Permit Requirements Form (section III) Fee Payment Form with payment attached Fingerprint cards or district verification of background check Official transcripts U.S. and Wyoming Constitution (verification by transcript or exam) Institutional recommendation (for School Nurse only) Verification of Employment Verification of Work History (for Out of State applicants only) PTSB approved workshop credit (for reinstatement applicants or to meet coaching requirements for ASEP and/or Care & Prevention only) N/A By checking this box and signing below, I acknowledge that I am submitting a COMPLETE application packet to PTSB. I understand that if any portion of the application packet is incomplete, the entire application packet will be returned to me unprocessed. **Incomplete or unsigned application packets will be returned to the applicant unprocessed** Applicant Signature Date

7 Fee Payment Form Make fees payable to PTSB or Professional Teaching Standards Board Payable by check, money order, cashier s check, or credit card. Please be sure the applicant s full name is written on the check. Individual Application Fees Substitute Teacher (5 yr) $50.00 School Nurse/Substitute School Nurse (5 yr) $50.00 Lifetime Substitute Teacher $50.00 Trade & Technical (PIC) (5 yr) $ Head or Assistant Coach (5 yr) $50.00 Native Language Permit (2 yr) $75.00 Transitional Coach (5 yr) $ Internship (1 yr) $50.00 Fingerprint Processing Fee (If Applicable) If you have a current permit or license from PTSB you do not have to submit fingerprint cards or pay the fingerprint fee. Fingerprint fee $50 Staple check or money order here or complete credit card information below: Cardholder Name (please print): Cardholder Billing Address: Street/PO Box City State Zip Visa MasterCard Discover Credit Card Number: Expiration Date CVC Code (found on signature line, 3 to 4 digits) - Cardholder Signature Date Permit Application Fee Fingerprint Processing Fee (if applicable) $ $ (ONE PAYMENT MAY BE SUBMITTED TO COVER ALL APPLICABLE FEES) Total Amount of Fees $ - 6 -

8 Wyoming Educator Permit Application Form Social Security No. I. APPLICATION INFORMATION - - Last Name First name MI Maiden / Other Name Mailing Address Address City State Zip Code Date of Birth / / Gender (optional) Address American Indian or Alaska Native Anglo, Caucasian, White, not of Hispanic origin. Asian, Japanese, Chinese, Vietnamese, Korean, Filipino. Phone Home ( ) Work ( ) Ethnicity (optional) Black, African American, not of Hispanic origin. Male Hispanic, Chicano, Cuban, Puerto Rican, Latino, Mexican American Native Hawaiian or other Pacific Islander. Female II. LICENSURE INFORMATION Mark either yes or no for EACH question and attach any relevant documentation Yes No Has any state(s) revoked, suspended, restricted, conditioned, refused to renew, or otherwise disciplined any professional license held by you? Yes No Have you ever voluntarily surrendered any professional license or allowed any professional license held by you to lapse or expire? Yes No Have you ever resigned a teaching position at the request of your employer or while you were under investigation by your employer? Yes Yes Yes No No No Have you ever been investigated, or are you currently being investigated, for an alleged violation of any state licensing or other regulatory provision, rule or law? Have you been convicted of any felony committed after July 1, 1996? ( Convicted means an unvacated determination of guilty by any court having legal jurisdiction of the offense and from which no appeal is pending. Pleas of guilty and nolo contender shall be deemed convictions for the purposes of this section. Dispositions pursuant to W.S or shall not be convictions for purposes of this section. Felony means a criminal offense for which the penalty authorized by law included imprisonment in a state penal institution for more than one (1) year and includes an offense committed in another jurisdiction which, if omitted in this state, would constitute a felony as defined in this paragraph.) Have you ever been convicted of any violation of criminal law, excluding minor traffic offenses? (Driving under the influence convictions are not minor traffic offenses and must be reported.) IF YOU ANSWERED YES TO ANY OF THE QUESTIONS ABOVE, PLEASE PROVIDE A SIGNED EXPLANATION AND COPIES OF ANY SUPPORTING DOCUMENTS (i.e. Final Order, Settlement Agreement, Judgment and Sentence, etc.) (If you have submitted explanations in a previous application, a duplicate explanation is not required.) Yes No Are you legally eligible to work in the United States? Yes No Do you currently hold a valid Teaching or Administrative Certificate or License? If yes, attach a copy. Yes No Do you currently have a teaching position in Wyoming? School District Name and Number School Grade Level Subject I affirm under penalty of perjury under the laws of the State of Wyoming that all information included in this application is true, correct and complete. I understand that knowingly providing false information may be grounds for denial or annulment of a license. Applicant Signature Date - 7 -

9 III. INDIVIDUAL LICENSURE REQUIREMENTS Please indicate which type of permit you are applying for by checking the appropriate box and completing all information in the corresponding section. Substitute Teacher Permit Application Fee: $50.00 Applicants may apply for the Substitute Teacher Permit either through the Traditional Route or the Alternative Route listed below. An individual who holds this permit is eligible to substitute teach in any classroom, grades K-12. Traditional Route A Substitute Teacher Permit obtained through the Traditional Route is valid for five years. An individual who holds this permit is eligible to substitute teach in any classroom, grades K-12. *Requirements: Check the box below to indicate that you have met the requirement (transcripts MUST be attached). Completion of Sixty-five (65) semester hours from a regionally or NCATE accredited institution (If you do not have 65 semester hours, complete the Alternative Route below). Check with school district for program information. Alternative Route Applicants who have not earned 65 semester hours of college credit may choose to apply for a Classroom Substitute Teacher Permit through the Alternative Route. A Substitute Teacher Permit obtained through the Alternative Route is valid for five years. An individual who holds this permit is eligible to substitute teach ONLY at the grade levels for which classroom observation has been verified by a district superintendent (see below). *Requirements: Check each box below to indicate that you have met the requirement (documentation verifying each requirement MUST be attached). High School Diploma or GED School Attended City & State Date Graduated 24 total hours of in-service training In-service training workshops are offered through individual Wyoming school districts and through PTSB directly. Please contact your school district for workshop dates. To find current PTSB workshops being offered, please visit our website and see the link under Professional Development/Renewal Credit. 10 Hours of classroom observation The applicant must contact the school district directly and make arrangements with the district superintendent to complete the 10 hours of classroom observation required. Verification by the district superintendent that the applicant has completed the required In-service training and classroom observation listed above. The applicant must have the district superintendent complete the following information: As representative of County School District #, I hereby verify that the applicant has completed 24 hours of in-service training as well as 10 hours of classroom observation in the following areas: Elementary Junior High/Middle Secondary All Three District Representative Signature Date Lifetime Substitute Teacher Permit Application Fee: $50.00 A Lifetime Substitute Teacher Permit never has to be renewed. An individual who holds this permit is eligible to substitute teach in any classroom, grades K-12. Please Note: The Lifetime Substitute Teacher Permit is ONLY available to teachers who have retired from a Wyoming school district. If you were not working as a teacher in a Wyoming school district at the time of your retirement, you are NOT eligible for this permit. You must apply for the standard Classroom Substitute Teacher Permit (see above). *Requirements: Check ONE of the boxes below to indicate that you have met the requirement (documentation MUST be attached). Verification of Retirement by attaching a letter from the district superintendent Verification of Retirement by attaching a statement or letter from the district human resources department - 8 -

10 Head Coach Permit Application Fee: $ A Head Coach Permit is valid for five years. An individual who holds this permit is eligible to coach ONLY the specific sport for which he/she holds a permit. Please Note: If you DO NOT meet all requirements for the Head Coach permit, you may be eligible for a Transitional Coaching Permit. Refer to the Transitional Coaching Permit section later in this application. Please indicate the sport-specific area(s) for the Coaching Permit for which you are applying. Basketball Football Golf Gymnastics Skiing Soccer Swimming Tennis Track Volleyball Wrestling All applicants for a Head Coach Permit must meet the following requirements Check each box below to indicate that you have met that specific requirement; then indicate how you met the requirement by checking the appropriate item under each (documentation verifying each requirement MUST be attached). High School Education This requirement has been met by (choose one): Diploma GED Current 1 st Aid/CPR Training This requirement has been met by (choose one): College Transcript American College of Emergency Physicians (ACEP) Sport First Aid Course Red Cross National Federation of Interscholastic Athletic Coaching (NFICEP) Sport First Aid Course American Heart Association Prevention and Care of Athletic Injuries (equivalent to 2 semester hours) This requirement has been met by (choose one): College Transcript National Athletic Trainers Association (NATA) Scientific Foundations of Coaching This requirement has been met by (choose one): College Transcript Program Athletic Coaching Education (PACE) Passing score on National High School Athletic Coaching Certification Exam American Sport Education Program (ASEP) athletic coaching education sports science course National Federation of Interscholastic Athletic Coaching (NFICEP) athletic coaching education sports science course Prior Coaching Experience or Sport-Specific Training This requirement has been met by (choose one): Three (3) years of successful experience as an assistant coach, verified by supervisor on official school letterhead Theory of Coaching the Specific Sport met by (choose one): College Transcript Sport-specific techniques and tactics course taken through (NFICEP) or ASEP Child Development and Psychology This requirement has been met by (choose one): A three (3) semester hour course in Lifespan-Human Development College Coursework in Child Development and Psychology College credit in Child Growth & Development AND College Credit in Adolescent Psychology Course Code and Title Course Code and Title - 9 -

11 Assistant Coach Permit Application Fee: $ An Assistant Coach Permit is valid for five years. An individual who holds this permit is eligible to coach ONLY the specific sport for which he/she holds a permit. Please Note: If you DO NOT meet all requirements for the Assistant Coach Permit, you may be eligible for a Transitional Coaching Permit. Refer to the Transitional Coaching Permit section later in this application. Please indicate the sport-specific area(s) for the Coaching Permit for which you are applying. Basketball Football Golf Gymnastics Skiing Soccer Swimming Tennis Track Volleyball Wrestling All applicants for an Assistant Coach Permit must meet the following requirements Check each box below to indicate that you have met that specific requirement; then indicate how you met the requirement by checking the appropriate item under each (documentation verifying each requirement MUST be attached). High School Education This requirement has been met by: Diploma GED Current 1 st Aid/CPR Training This requirement has been met by: College Transcript American College of Emergency Physicians (ACEP) Sport First Aid Course Red Cross National Federation of Interscholastic Athletic Coaching (NFICEP) Sport First Aid Course American Heart Association Prevention and Care of Athletic Injuries (equivalent to 2 semester hours) This requirement has been met by: College Transcript National Athletic Trainers Association (NATA) Scientific Foundations of Coaching This requirement has been met by: College Transcript Program Athletic Coaching Education (PACE) Passing score on National High School Athletic Coaching Certification Exam American Sport Education Program (ASEP) athletic coaching education sports science course National Federation of Interscholastic Athletic Coaching (NFICEP) athletic coaching education sports science course Prior Coaching Experience or Sport-Specific Training This requirement has been met by (choose one): One (1) year of successful experience as an assistant coach, verified by supervisor on official school letterhead Theory of Coaching the Specific Sport met by (choose one): College Transcript Sport-specific techniques and tactics course taken through (NFICEP) or ASEP

12 Transitional Coaching Permit Application Fee: $ A Transitional Coaching Permit is valid for three years and is issued when a coaching applicant is unable to meet all of the requirements for a standard Head or Assistant Coach Permit. An individual who holds this permit is eligible to coach ONLY in the specific position for which he/she has been hired. Transitional Coaching applicants must meet ALL of the following requirements (documentation verifying each MUST be attached) High school diploma or GED Verification of Employment (see supplemental forms) in a coaching position for which the transitional coaching permit will be issued Current 1 st Aid/CPR Training (include copies of certification, front and back) This requirement has been met by: College Transcript American College of Emergency Physicians (ACEP) Sport First Aid Course Red Cross National Federation of Interscholastic Athletic Coaching (NFICEP) Sport First Aid Course American Heart Association By signing below, I understand that I have up to three (3) years from the date my Transitional Coaching Permit is issued to complete all additional requirements to obtain a Standard Head or Assistant Coach Permit Applicant Signature Date: Internship Permit Application Fee: $50.00 An Individual who holds an Internship Permit is eligible to serve in a specific assignment as an intern for a Wyoming public school. It is a temporary permit good for one calendar year. Before applying for the Internship Permit, the applicant must make arrangements with a school district for an available internship position. If the school district chooses, an intern may be paid during an internship. Please Note: The Internship permit is required for ALL education personnel who will be performing the role of an intern, regardless of whether the position is paid or unpaid. I am applying for an internship permit for: District Superintendent School Principal School Psychologist School Counselor Program Director/Coordinator/Supervisor School Social Worker *Requirements (documentation verifying each of the requirements MUST be attached) Enrollment letter from the applicant s education institution stating acceptance into an internship program Program enrolled in: Expected graduation date: Transcript showing most current courses Letter verifying acceptance in an internship position with a school district AND verification of supervision during the internship period Native Language Permit Application Fee: $75.00 A Native Language Permit is valid for two years. An individual who holds this permit is eligible to teach the Arapahoe and/or Shoshoni language(s), grade levels K-12. *Permit Requirements: Check each box below to indicate that you have met the requirement (documentation for each requirement MUST be attached). Written approval from the Tribal Council Committee Written Verification of Employment (see supplemental forms) from the school district which has employed you

13 Trade and Technical (PIC) Permit Application Fee: $ A Trade and Technical Permit (PIC) is valid for five years. An individual who hold this permit is eligible to teach in one of the fields listed below, grade levels I am applying for a Trade and Technical Permit in the following area(s): Auto Body Auto Mechanics Aviation Building Trades Careers Certified Nursing Assistant Instructor Chef Computer Technology Cooperative Vocational Education Drafting Electrical Electronics Food Services Graphics Health Occupations Horticulture Industrial Education Machine Shop Mechanics Outdoor Living Radio/TV/Media Technology Sports Medicine Trade and Industrial Education Welding Woodworking *Requirements: Check each box below to indicate that you have met the requirement (documentation verifying each requirement MUST be attached). High School Diploma or GED Minimum two years work experience (in addition to any educational training the applicant may have obtained in his/her occupational specialty) Valid license in the applicant s occupational specialty when one is required by state or federal statutes Plan for Continued Professional Advancement School Nurse Permit / Substitute School Nurse Permit Application Fee: $50.00 The School Nurse and Substitute School Nurse Permits are valid for five years. An individual who holds this permit is eligible to provide health services to students in grades K-12. Note: Applicants who have completed a bachelor s degree or higher in Nursing are eligible to apply for the Wyoming Educator License. These applicants should submit the application for Wyoming Educator License and select the School Nurse option. Full-time School Nurse *Requirements: Check each box below to indicate that you have met the requirement (documentation for each requirement MUST be attached). Copy of current Wyoming RN license or a letter from the Board of Nursing verifying licensure Institutional Recommendation to be completed by College or University (see Supplemental Forms) Substitute School Nurse *Requirements: Check the box below to indicate that you have met the requirement (documentation MUST be attached). Copy of current Wyoming RN license or a letter from the Board of Nursing verifying licensure

14 Supplemental Forms The following section provides various forms that you may need to submit with your complete PTSB application packet. Not all forms are necessary for every licensure area. Verify which forms you may need by double-checking the general instructions at the beginning of this application, as well as the specific requirements under your licensure type, and by filling out the Application Checklist completely.

15 Instructions for Completing Fingerprint Cards To avoid delays in processing your application, please follow the instructions for fingerprint cards on this form carefully. BEFORE submitting your fingerprint cards, be aware that: Fingerprint cards that have been folded, stapled, or mutilated in any way will be returned to the applicant unprocessed. Fingerprint cards with smudged or unreadable prints will be returned to the applicant unprocessed. Fingerprint cards completed in anything other than black ink will be returned to the applicant unprocessed. Fingerprint cards that are not completed as instructed will be returned to the applicant unprocessed. ALL INFORMATION MUST BE IN BLACK INK ONLY COMPLETE THE FOLLOWING FIELDS ON BOTH THE BLUE AND ORANGE FINGERPRINT CARDS Left Side Signature of Applicant, Residence of Applicant. Date and Signature of Official taking Fingerprints (must be completed by the Official). Middle Column Last name, First name, Middle Name (top of card), Aliases (only if you have used other names), Citizenship, Social Security Number. Right side Sex, Race, Height, Weight, Eyes, Hair, Place of Birth, Date of Birth. COMPLETE THE FOLLOWING FIELDS ON THE BACK OF THE ORANGE FINGERPRINT CARD: Signature of Applicant and Date (must be completed in the presence of a Notary Public). Orange Card Back Side Notary Public is to fill out his/her portion (check to be sure the Notary has stamped the card with his or her official seal). Last, First, Middle Name (to be printed or typed in by the applicant).

16 UNITED STATES/WYOMING CONSTITUTION Wyoming State Statute requires applicants to demonstrate knowledge of the U.S. and Wyoming Constitutions either through coursework or by successfully passing an exam. Reinstating applicants have previously met this requirement and do not need to submit documentation. Demonstration of Knowledge through Coursework Courses must cover U.S. History prior to 1865 and include the study of the Constitution. Political Science courses may be counted if they covered the Constitution. Course descriptions may be required. Graduates from a Wyoming Community College or the University of Wyoming have already met this requirement. Please list coursework you have taken to meet this requirement and circle or highlight the corresponding course(s) on your transcript. Course Prefix & Number Course Title Institution Where Credit was Earned Semester Hours Final Grade Year Course Completed Demonstration of Knowledge through Exam Exams may be taken at any Wyoming school district administration office or the Professional Teaching Standards Board office. Study guides are available at the local school administration building or superintendent s office, at the PTSB office, and online at When taking the U.S. and Wyoming Constitution exams, the applicant must have the exam proctor complete the information on the bottom portion of the form below. Once the exams are completed, have the proctor return the completed form and completed exams directly to you in a sealed envelope so that you may submit the results as part of your complete application packet. Out-of-State Applicants Out-of-State applicants may request that exams be sent to a school administrator in the applicant s state. You may PTSB at ptsbtemp@state.wy.us to request that this form be sent directly to the out-of-state proctor. Please be sure to include the full name and correct address of the Proctor in your request. Applicant Information Applicant s Full Name Social Security No. - - Address Street City State Zip This section to be completed by the exam Proctor To the Administrator/Proctor: Please complete the information below and return this form to the applicant. PROCTOR INFORMATION Name of Proctor School District Address Mailing Address City State Zip Code Administrator/Proctor Signature By signing below, I verify that the above individual took the appropriate exam(s) and received the scores I have indicated. Administrator/Proctor Date Exam Score Received: United States Constitution Wyoming Constitution

17 Institutional Recommendation (School Nurse Applicants Only) To the Applicant: Please complete the personal information in this section, then send this form to the Dean of your College/University to complete. Applicant Information Applicant s Full Name Social Security No. - - Address Street City State Zip ` **YOU MUST INCLUDE AN OFFICIAL TRANSCRIPT ** To the Dean: Please complete this section and return to the applicant. Graduation State: College Name: Date: Degree(s): Major or certification area: Is this person eligible to hold an RN license in your state (required for recommendation)? Yes No If the applicant is not eligible for an institutional recommendation please do not sign this page. Please return this form to the applicant and attach an explanation statement. If you know of any reason this applicant should not serve as a school nurse in Wyoming schools, please send a separate statement to WPTSB, 1920 Thomes Ave., Suite 400, Cheyenne WY The college education program completed by this applicant is accredited by: Is the program state approved? Yes No Name of State: Do you require graduates to take a test to receive an Institutional Recommendation Yes No Name of test required: Passing score required: Can you verify score? Yes No IF YES -Score received: Date test taken: Print Name: Title: Signature: Date: Only the signature of a Certification Officer, Dean of the College or designee can be accepted. PLACE COLLEGE SEAL HERE (Application cannot not be processed without the seal)

18 Verification of Work History (For Out-of-State Applicants Only) Applicant Information Applicant s Full Name Social Security No. - - Address Street City State Zip Telephone No. address Home ( ) Work ( ) Work History (List all teaching, administrative, or other school experience for the past 10 years. Include only Full-time Assignments) Grades Taught Staffing Assignment(s) (List only full-time assignments) Employment Dates Full Time Part Time Name of District or State-Accredited Private School This section to be completed by applicant s School Administer To the Administrator or Board Chair: Please verify the applicant s teaching and/or administrative experience listed above 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: WPTSB, 1920 Thomes Ave. Suite 400, Cheyenne, WY Authorized Signature Printed Name Title School District (Include District No.) Telephone No. ( ) 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

19 Verification of Employment Applicant Information Applicant s Full Name Social Security No. - - Address Street City State Zip Telephone No. address Home ( ) Work ( ) This section to Be Completed by the Employer The above applicant is applying to the Wyoming Professional Teaching Standards Board for an Educator Permit and, as a requirement of his or her approval, must provide proof of past or present employment. Verification of Present or Past Employment Dates of Employment Position Held by Applicant From: To: Authorized Signature Printed Name Title Company Name or School District (Include District No.) Telephone No. ( ) 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