LICENSE RENEWAL APPLICATION FOR PRIVATE TRADE, VOCATIONAL OR TECHNICAL SCHOOLS

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1 DAVID Y. IGE GOVERNOR KATHRYN S. MATAYOSHI SUPERINTENDENT STATE OF HAWAI`I DEPARTMENT OF EDUCATION nd Avenue, Room 209 Honolulu, Hawaii Phone: (808) Fax: (808) LICENSE RENEWAL APPLICATION FOR PRIVATE TRADE, VOCATIONAL OR TECHNICAL SCHOOLS Private Trade, Vocational or Technical (PTVT) School License renewal applications are processed every two years during odd-numbered years (i.e. 2015, 2017, etc.) and are due by July 1 st of the expiring year. Licenses are granted from September 1 to August 31 for two years. The license renewal fee is $50.00 and must be submitted with the renewal application. A change in ownership requires the submittal of an Initial License Application. The current license cannot be renewed. Instructions and Checklist: Review Hawaii Administrative Rules, Title 8, Chapter 101, Licensing of Private, Trade, Vocational or Technical Schools. All schools and staff must comply with the Hawaii Administrative Rules, Title 8, Chapter 101. A licensed school shall make available a copy of this chapter to members of the staff and students upon request. REQUIRED DOCUMENTS o School Information (PTVT Form 1) o Request for License Renewal (PTVT Form 2) o Personnel (PTVT Forms 3-6) o Curriculum (PTVT Forms 7-9) o Annual Summary Reports (PTVT Form 10-12) o Brochure/Catalog and Sample of School Certificate o Surety Bond (Affidavit) o License Renewal Fee o Facilities o Department of Health o City and County Building Division o City and County Fire Department o Floor Plan o Certification of Applicant AN AFFIRMATIVE ACTION AND EQUAL OPPORTUNITY EMPLOYER

2 LICENSE RENEWAL APPLICATION For Private Trade, Vocational, or Technical Schools Instructions and Checklist (continued): SCHOOL INFORMATION o Complete School Information (PTVT Form 1) REQUEST FOR LICENSE RENEWAL o Complete Request for License Renewal (PTVT Form 2) PERSONNEL Instructors o New Application for Professional Staff Certificate (PTVT Form 3) Evidence that a standard learning period has been completed and passed for the trade or vocation noted (i.e. resume, transcripts, diploma/certificate) Employment verification of a minimum of 5,400 hours (approximately 3 years) of work experience for the trade or vocation noted Current Hawaii licenses for the trade or vocation noted (i.e. massage, acupuncture, crane operations, etc.) Current and valid tuberculosis clearance certificate o Continuing Application for Continuing Instructors (PTVT Form 4) New licenses and certificates, if applicable Updated Summary of Instructors Form (PTVT Form 5) List all instructors in alphabetical order Submit a revised list if there are changes during the school year Principal o New Non-Instructional staff members must submit a current and valid tuberculosis (TB) clearance certificate Principal Certification Form (PTVT Form 6) Documentation of Training and Experience 3 Letters of Verification o Continuing Mark continuing on School Information Form (PTVT Form 1) Note: After a school has been licensed, any changes shall be reported to the Hawaii State Department of Education within five (5) business days from the date of change. Changes can be sent via to ptvt@hawaiidoe.k12.hi.us. Hawaii State Department of Education 2

3 LICENSE RENEWAL APPLICATION For Private Trade, Vocational, or Technical Schools Instructions and Checklist (continued): CURRICULUM Complete Course Log and Information Form (PTVT Form 7) Complete Course Description Form (PTVT Form 8) If applicable, complete Course of Study (PTVT Form 9) ANNUAL SUMMARY REPORTS Complete Annual Summary of Courses, Fees, and Enrollment (PTVT Form 10) Complete Annual Summary of Fiscal Operations (PTVT Form 11) Attach a copy of the most recent Financial Report (audited/unaudited) Complete Projected Summary of Fiscal Operations (PTVT Form 12) BROCHURE/CATALOG Current curriculum (course of study, course descriptions, etc.) Course Fees (Tuition, books, supplies, and other fees) Student Rights Refund Policy Grading Policy Sample Certificate SURETY BOND (AFFIDAVIT) Submit a current affidavit demonstrating Surety Bond is and will be current for the program years of licensure. LICENSE RENEWAL FEE Submit License Renewal Fee of $50.00 payable to the Hawaii Department of Education. Hawaii Revised Statutes, Section , Assessment and collection of service charges for dishonored payments, requires all DOE schools and offices receiving revenues or other monies on behalf of the State to assess and collect a service charge in the amount of $25.00 for any remittance for payment that is dishonored for any reason. Hawaii State Department of Education 3

4 LICENSE RENEWAL APPLICATION For Private Trade, Vocational, or Technical Schools Instructions and Checklist (continued): FACILITIES/CERTIFICATES OF INSPECTION If a school relocates to a new address, it must submit updated health, building, fire, and floor plans. Evidence provided must indicate all requirements have been met. County Building Department (which includes the maximum occupant load) State Department of Health Fire Inspection Floor Plan Contact Information Sanitation Compliance Hawaii State Department of Health Sanitation Branch 591 Ala Moana Blvd., 1st Floor Honolulu, Hawaii Phone: Fire Safety Requirements Fire Prevention Bureau 636 South Street Honolulu, Hawaii Phone: Safety and Building Code Compliance City and County of Honolulu Building Division Department of Planning and Permitting Building Division 650 South King Street #7 Honolulu Hawaii Phone: (leave a voice message to return your call) The Hawaii State Department of Education does not require submission of certificates of clearance showing compliance with the Hawaii Occupation and Safety Health (HIOSH) and the Americans with Disabilities Act (ADA). However, all licensed schools are responsible for the compliance with applicable codes and regulations. For more information and assistance, contact the following offices: Hawaii State Department of Labor and Industrial Relations Hawaii Occupational Safety and Health Division Consultation and Training Branch 830 Punchbowl Street, Room 423 Honolulu, Hawaii Phone: or Note: Go to website and read regulations ( Disability and Communication Access Board 919 Ala Moana Blvd., Room 101 Honolulu, Hawaii Phone: Hawaii State Department of Education 4

5 CERTIFICATION OF APPLICANT LICENSE RENEWAL APPLICATION For Private Trade, Vocational, or Technical Schools By submitting this licensing application, I hereby attest that I have reviewed the contents for accuracy. All forms submitted are in compliance with Hawaii Administrative Rules, Title 8, Chapter 101. In addition, I certify the adherence to provisions of the Hawaii Revised Statutes Sections 302A-424 to 302A-428. Signature of Authorized Officer Print Name Title Hawaii State Department of Education 5

6 SCHOOL INFORMATION (PTVT Form 1) This information should reflect what appears on the current school license. Name of School Provider/Owner (Registered Trade Name) School Address (Classroom Location) Business/Mailing Address Business Telephone Fax Number E mail Address Web Page URL School Administrator (Principal) School Administrator s Residence Address Phone Number E mail Address Principal is: Continuing New (If new, submit Principal Certification Form and accompanying documents) Vocation(s) List State General Excise Tax Number

7 REQUEST FOR LICENSE RENEWAL (PTVT Form 2) The school license is limited to the specific Name, Location, and Vocation as stated on the license. Check one of the following: Requesting that a license be issued the same as the previous year. There are no changes and the license information is correct. Requesting a change in the license due to the following: Change in School Name New Name Previous Name Change in Location New Address Previous Address Note: Updated health, building, fire, and floor plans stating that all requirements have been met must accompany this form. Changes/Additions to Vocation Listing New Vocation(s) List Previous Vocation(s) List Change in Mailing Address New Address Previous Address Change in Ownership Note: A change in ownership status voids the current license. The school must submit a new initial application.

8 APPLICATION FOR PROFESSIONAL STAFF CERTIFICATE (PTVT Form 3) Complete this form and attach the following for each instructor: Evidence that a standard learning period has been completed and passed for the trade or vocation noted (i.e. resume, transcripts, diploma/certificate) Employment verification of a minimum of 5,400 hours (approximately three (3) years) of work experience for the trade or vocation noted Current Hawaii licenses for the trade or vocation noted if required of instructors by law or ordinance Current and valid tuberculosis clearance certificate A. PERSONAL INFORMATION Legal Name (Last, First, Middle) Social Security Number xxx xx Mailing Address Phone Number E mail Address Trade/Vocation Certification Areas B. EDUCATIONAL AND PROFESSIONAL TRAINING Name and Location of Schools Attended (High, Technical, Vocational Schools and Colleges) Area of Study or Major From (mm/yy) To (mm/yy) Certificates Diplomas Degrees Award (mm/yy) C. TEACHING EXPERIENCE (if none leave blank) Name and Location of Schools Attended (High, Technical, Vocational Schools and Colleges) Discipline or Area Taught From (mm/yy) To (mm/yy) Years Months D. WORK EXPERIENCE OTHER THAN TEACHING Name and Location of Firm Nature of Work From (mm/yy) To (mm/yy) Years Months Hawaii State Department of Education Page 1 of 2

9 APPLICATION FOR PROFESSIONAL STAFF CERTIFICATE (PTVT Form 3) E. APPLICANT CERTIFICATION STATEMENT I certify that the foregoing information in Sections A, B, C, and D are correct to the best of my knowledge. I have also attached the required documents. Signature of Applicant F. ASSURANCES BY THE PRINCIPAL All documents necessary to apply for the Professional Staff Certificate (PSC) are attached. I have reviewed and verified the applicant s training, background, and experience. The applicant is qualified to serve as an instructor and a member of my teaching faculty. Name of School Hawaii State Department of Education Page 2 of 2

10 APPLICATION FOR CONTINUING INSTRUCTORS (PTVT Form 4) Complete this form and attach the following for each instructor: New licenses and certificates, if applicable A. PERSONAL INFORMATION Legal Name (Last, First, Middle) Social Security Number xxx xx Name of School There are changes to my personal information as noted below: B. CHANGES TO PERSONAL INFORMATION Mailing Address Individual Licensure Commission on Board License Number Expiration Phone Number E mail Address Position Title Course(s) Taught C. ASSURANCES BY THE INSTRUCTOR AND PRINCIPAL I certify the information provided in Sections A and B are accurate to the best of my knowledge and belief. I have also attached appropriate documents if applicable. Signature of Applicant

11 SUMMARY OF INSTRUCTORS FORM (PTVT Form 5) Instructions List all instructors in alphabetical order Submit a revised list if there are changes since the last application Non Instructional staff members must submit a current and valid tuberculosis (TB) clearance certificate A. NEW INSTRUCTIONAL STAFF Legal Name (Last, First, Middle) Individual Licensure Social Security Number xxx xx Course(s) Taught Commission on Board License Number Expiration Teacher Certificate No. Legal Name (Last, First, Middle) Individual Licensure Social Security Number xxx xx Course(s) Taught Commission on Board License Number Expiration Teacher Certificate No. Legal Name (Last, First, Middle) Individual Licensure Social Security Number xxx xx Course(s) Taught Commission on Board License Number Expiration Teacher Certificate No. Legal Name (Last, First, Middle) Individual Licensure Social Security Number xxx xx Course(s) Taught Commission on Board License Number Expiration Teacher Certificate No. B. NON INSTRUCTIONAL STAFF (Attach TB clearance certificate) Legal Name (Last, First, Middle) Position Hawaii State Department of Education Page 1 of 2

12 SUMMARY OF INSTRUCTORS FORM (PTVT Form 5) C. RETURNING STAFF (Must have Application for Professional Staff Certificate on file) Legal Name (Last, First, Middle) Teacher Certificate No. D. PRINCIPAL S SIGNATURE Name of School Total Number of Staff Hawaii State Department of Education Page 2 of 2

13 PRINCIPAL CERTIFICATION FORM (PTVT Form 6) Complete this form and attach the following: Documentation of Training and Experience Three (3) Letters of Verification testifying to the character, ability, and competency to operate the school as proposed A. PERSONAL INFORMATION Legal Name (Last, First, Middle) Social Security Number xxx xx Mailing Address Phone Number E mail Address Name of School B. CERTIFICATION I certify that I have adequate training and experience to be principal of the school. As principal of the school, I shall be responsible for: Complying with all applicable State, County, and Department of Education policies. Providing reports and information as required by the Department of Education. Informing the Department of Education of changes in school policies, programs, facilities, tuition, calendar, and all other matters affecting the status of the school as originally licensed. Providing all advertisements, recruitment procedures employed by representatives of the school, published materials, and public relations activities. Directing and supervising the school s staff and program. Assuring that all facilities comply with State and City and County requirements. C. OWNER VERIFICATION AND ASSURANCE The above individual will serve as principal of the school. Evidence of the following is attached: Documentation of Training and Experience Three (3) Letters of Verification testifying to the character, ability, and competency to operate the school as proposed I shall comply with all applicable State, County, and Department of Education policies. Signature of Owner

14 COURSE LOG AND INFORMATION FORM (PTVT Form 7) Instructions Submit one sheet for each vocation/trade Evening classes must be approved by the Hawaii State Department of Education A. SCHOOL INFORMATION School Vocation/Trade Unit measurement utilized by school: Trimester Quarter Credit Clock Hours B. COURSE LOG AND INFORMATION Course Title Instructor Time of Class Start Finish Class s Start Finish Length of Class Credits or Clock Hours Projected Enrollment Night Course? Yes or No

15 COURSE DESCRIPTION FORM (PTVT Form 8) Submit one form for each course/class. A. SCHOOL INFORMATION School Vocation/Trade B. COURSE DESCRIPTION Course Title Instructor(s) Projected Enrollment Curriculum Description (What will be covered in the course/class and what equipment will be needed?) Objectives or Standards: (What is the expectation of the student at the end of the course/class?) Evaluation: (How will the instructor evaluate the successful completion of the course/class?) C. LENGTH OF COURSE/CLASS Total Weeks Total Days Number of Sessions Number of Credits/Clock Hours First Class Last Class D. EXPENSES FOR THE COURSE/CLASS Tuition Books Registration Fees Other Fees E. PRINCIPAL SIGNATURE

16 COURSE OF STUDY (PTVT Form 9) Instructions Submit one sheet for each Vocation/Trade A. SCHOOL INFORMATION Name of School Vocation/Trade B. COURSE OF STUDY C. DOCUMENTATION UPON COMPLETION Upon completion of the above, the student will receive the following: Certificate Transcript Other:

17 ANNUAL SUMMARY OF COURSES, FEES, AND ENROLLMENT (PTVT FORM 10) Instructions Submit one sheet for each vocation/trade Include all Federal, State, and Private reimbursements for each class in the appropriate area (i.e. tuition, books, etc.) A. SCHOOL INFORMATION School Vocation/Trade School Year to B. COURSE LOG AND INFORMATION Course Title Fees Total Length of Course Number of Students Tuition Registration Books/Supplies Other (List) Days/Sessions Weeks Credit/Clock Hours Enrolled Graduated/Completed

18 ANNUAL SUMMARY OF FISCAL OPERATIONS (PTVT Form 11) Instructions Complete this form Attach a copy of the most recent Financial Report (audited/unaudited report) A. SCHOOL INFORMATION Name of School B. INCOME AND EXPENDITURES INCOME EXPENDITURES Registration $ Salaries $ Student Tuition $ Rent $ Federal Reimbursement $ Instructional Materials $ State Reimbursement $ Furniture $ Private Reimbursement $ Utilities $ Books/Supplies $ Office Supplies $ Other Fees (List) Other Expenses (List) TOTAL $ TOTAL $ C. NET PROFIT/LOSS Subtract income total from expenditure total $

19 PROJECTED SUMMARY OF FISCAL OPERATIONS (PTVT Form 12) A. SCHOOL INFORMATION Name of School B. PROJECTED INCOME AND EXPENDITURES INCOME EXPENDITURES Registration $ Salaries $ Student Tuition $ Rent $ Federal Reimbursement $ Instructional Materials $ State Reimbursement $ Furniture $ Private Reimbursement $ Utilities $ Books/Supplies $ Office Supplies $ Other Fees (List) Other Expenses (List) TOTAL $ TOTAL $ C. PROJECTED NET PROFIT/LOSS Subtract income total from expenditure total $ D. ASSETS AND DEBTS Name of Lender Address Amount Capital Assets (Cash) $ $ Other Assets $ $ Debts $ $