! Initial!Provisional!Teaching!Certificate!!!!!!!!Interim!Occupational!Certificate!! Bachelor s!degree!in!education!

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1 CertificationOffice WayneStateUniversity 469Education Detroit,Michigan48202 (313)577"1601 (313)577"4944FAX ApplicationandProcedures Directions: Step1: Step2: Step3: Completetheapplicationandpriortosubmission,detachandkeepthedirectionpagesforyour reference. SubmitasignedPlanofWorkreflectingyourcurrentprogram. InitialProvisionalTeachingCertificate InterimOccupationalCertificate Bachelor sdegreeineducation AttachtranscriptsforcoursescompletedoutsideofWayneStateUniversityasdescribedbelow: UndergraduateApplicants:IfyouhavecompletedanycoursesoutsideofWayneStateUniversity that have not yet successfully transferred to WSU, you MUST submit unofficial copies of your transcriptwiththiscertificationapplicationandyoumusthaveofficialtranscriptsmailedto: WayneStateUniversity UndergraduateAdmissions AttentionTransferCreditUnit POBox02759 Detroit,MI48202"0759 PostBachelorApplicants:IfyouhavecompletedanyprerequisitecoursesoutsideofWayneState University,youMUSTsubmitunofficialcopiesofyourtranscriptwiththiscertificationapplication andyoumusthaveofficialtranscriptsmailedto: WayneStateUniversity Attn:FawneAllossery 469Education Detroit,Michigan48202 MATApplicants:IfyouhavecompletedanyprerequisitecoursesoutsideofWayneStateUniversity since the time of your admission, you MUST submit unofficial copies of your transcript with this certificationapplicationandyoumusthaveofficialtranscriptsmailedto: WayneStateUniversity Attn:KevinWilliams 489Education Detroit,Michigan48202

2 Step4: Step5: Step6: Attach current copies of ALL SUBJECT"AREA examination scores with this application. If your subject"areaexaminationscoreswerenotreleasedtowaynestateuniversity,pleaserequestan originalscorereportfromevaluationsystemsgroupofpearson.fromthescorereportinglinkon the MTTC website( select Test Results Request Form and enter 31 for the Institutional Code to have your scores sent to Wayne State University (31). Your scores mustb eddirectlyfromevaluationsystemsgroupofpearsontowaynestateuniversity.an originalscorereportisrequiredbythemichigandepartmentofeducationforverificationoftest scores. Note: Basic Skills Test Scores are not required with this application. The Basic Skills Test was requiredatthetimeofadmissionandthescoresareonfile. Attach a current (within 6 months of applying) Statewide Criminal History Check michigan.gov/ichat/ IftheStatewideCriminalHistoryCheckcontainsrecordsthatdonotbelongtotheindividualwhose name has been searched, follow the procedures for correcting an ICHAT Record: A JudgmentofSentence foranyconvictionmustbeonfilewithyourapplicationforthecollege of Education to recommend you for teacher certification to the Michigan Department of Education.Thisdocumentmaybeobtainedfromthecourtwherethematterwasadjudicated.In addition,anarrativedescribingthecircumstancessurroundingtheconvictionoractionfromyour perspectivemustbeonfile. AnyoneconvictedofanoffensewillNOTreceivea90"DayCertificationLetterasmandatedbythe MichiganDepartmentofEducation. StateBoardofEducationTeacherCertificateCode:R Certificates;denial,suspension,or revocation. (1)Thesuperintendentofpublicinstructionmayrefusetograntorrenew,ormaysuspendfora fixedterm,orrevoke,ormayimposereasonableconditionson,ateachingcertificateorstate boardapprovalgrantedpursuanttotheserulesforthefollowingreasons: (a) Fraud, or material misrepresentation, concealment or omission of fact in the application for,ortheuseof,ateachingcertificateorstateboardapproval. (b)convictionofanoffenselistedinmcl aormcl b. (2)Thesuperintendentofpublicinstructionmayrefusetograntorrenewateachingcertificateor a state board approval for failure or ineligibility of the applicant to meet the criteria for the applicablecertificationorstateboardapproval. PresenttoAcademicServicescurrentandsignedcertificationcardsinFirstAidandAdult/ChildCPR from an organization approved by the Michigan Department of Education. A list of approved organizations may be found on our Certification Website: /Certification.html.YoumustpresentyoursignedcertificationcardsinpersontoAcademicServices forverification.copieswillnotbeaccepted.

3 ForUndergraduateStudents: If you have applied for your degree by the deadline ( calendar.php) and have completed the requirements for your degree and certificate by the end of the semester,thisofficewillnotifytheuniversityrecordsofficethatalldegreerequirementshavebeenmet. The University Records Office will post your degree on your Wayne State transcript 2"3 business days after they receive notification from our office. The University Records Office will start processing diplomas after graduation.yourdiplomashouldb edapproximatelysixweeksafteryourgraduationdate.anyquestions regardingyourdiplomashouldbedirectedto: UniversityRecordsOffice 5057Woodward Room5051 Detroit,MI48202 (313)577"3531 ForTeacherCertificationCandidates(Undergraduate,Post"Bachelor&MAT): Apreliminaryauditofyourapplicationwillcommenceafterallnecessarydocumentshavebeenreceived.If youareenrolledinclassesduringthesemesteryouplantocompleteallcertification/degreerequirements,a FINALAUDITwillbecompletedAFTERALLgradeshavebeenposted.Processingistypicallycompletedwithin fourweeksafterthesemesterends. You will receive a temporary certification letter (90"Day Certification Letter) stating the level and area of certificationforwhichyouwillberecommendedtothemichigandepartmentofeducation(mde).thisletter canbeusedforemploymentpurposesasverificationthatallrequirementsfortheteachingcertificatehave beenmet.withinthevalidityofthisletter,wsuwillsendarecommendationtomdeforyourcertificateand MDEwillsendarequestfortherequisitefee(seebelow).Oncethefeehasbeenpaid,MDEwillmailyour teachingcertificatetoyou.anyoneconvictedofanoffensewillnotreceivea90"daycertificationletteras mandatedbythemichigandepartmentofeducation. Undergraduate Combined Degree students will receive a 90"Day Certification Letter after your degree is postedbytheschoolorcollegegrantingyourdegree. CertificationFees(SubjecttoChange): TypeofCertificate RequiredFee InitialProvisionalTeachingCertificate $ InitialInterimOccupationalCertificate $ ProfessionalEducationTeachingCertificate $ OccupationalEducationTeachingCertificate $ RenewalofProvisionalorInterimOccupationalCertificate $ AdditionalEndorsement $50.00 DONOTATTACHFEE YouwillbebilledbytheMichigan DepartmentofEducationupontheir receiptofwaynestateuniversity s recommendationforcertification.

4 Applicationfor: InitialProvisionalTeachingCertificate InterimOccupationalCertificate Bachelor sdegreeineducation Semesterandyearthatyouexpecttocompleterequirementsforyourteachingcertificateand/ordegree: Fall2009 Winter2010 Spring/Summer2010 Fall2010 Pleaseprintortypeyournameexactlyasyouwantittoappearonyourcertificate: Last First Middle(optional)Maiden(optional) Note:Ifyournamehaschanged,pleasecontacttheWayneStateUniversityRecordsOffice(313)577" 3531tochangeyournameorattachdocumentationreflectingnamechange. NumberStreet(includeapt.number)CityStateZip"Code " " / / PreferredPhoneNumberwithAreaCodeDateofBirth(MM/DD/YYYY) WayneStateUniversityStudentIDNumber SocialSecurityNumber TheSocialSecurityNumberisrequiredbytheState ofmichiganforprocessingtheteachingcertificate. E"mailAddress UndergraduateStudents: IhaveappliedformydegreeonlinethroughPipeline. (CheckboxandInitialontheline) Bachelor sdegreeforwhichyouareapplying(selectoneonly): BachelorofArtsinEducation(BA) Completionofforeignlanguagethroughtheintermediatelevel. BachelorofScienceinEducation(BS) CombinedBachelor sdegreefromthecollegeofliberalarts&science CombinedBachelor sdegreefromthecollegeoffine,performingandcommunicationarts DegreeOnly"NoCertification(selectoneonly): ExerciseandSportsScienceMajor DegreeinEducationwithNOcertification(Requiresanapprovedappeal) Gender: Male Female Post"Bachelor&MATStudents(selectoneonlyandcompletedegreeinformation): Post"BachelorTeacherCertificationProgram MasterofArtsinTeachingCertificationProgram NameofBachelorDegree DegreeGrantingInstitution DateofDegree

5 RevisedAugust26,2009InitialCertificationApplication Page2 TeachingCertificateforwhichyouarenowapplying(specifymajorand/orminorifapplicable): ElementaryProvisionalCertificate"AttachElementaryand,ifapplicable,majorand/orminorMTTCScores ElementaryOnly(K"5allsubjects,K"8inaself"containedclassroom) DateElementaryMTTCwaspassed ElementarywithMajorand/orMinor(K"5allsubjects,K"8inaself"containedclassroom,6"8 major/minor) NameofMajor DateMajorMTTCwaspassedortobetaken NameofMinor DateMajorMTTCwaspassedortobetaken SecondaryProvisionalCertificate(6"12inmajor/minor)" AttachmajorandminorMTTCScores NameofMajor DateMajorMTTCwaspassedortobetaken NameofMinor DateMajorMTTCwaspassedortobetaken K"12SecondaryProvisionalCertificate(MajorsinArt,Dance,KinesiologyPedagogyandMusic) and6"12intheminorsubjectarea(ifapplicable).attachmajor/minormttcscores NameofMajor DateMajorMTTCwaspassedortobetaken NameofMinor Endorsementsforwhichyouarenowapplying"AttachappropriateMTTCScores ListdateMTTCwaspassedortobetaken Autism(K"12) CognitiveImpairment(K"12) EarlyChildhood EmotionalImpairment(K"12) LearningDisabilities(K"12) DateMajorMTTCwaspassedortobetaken MiddleLevel ForeignLanguageandBilingual"BiculturalEducationCandidates: ForeignLanguageMajors&Minors(withMTTCscoresafterJuly2007):PassingscoreonOPI Bilingual"BiculturalEducation(admittedwinter2007andthereafter): PassingscoreonOPI&WPT ForeignLanguagewithK"12Certification(MajorsOnly) " RequiresCompletionofAdditionalCourses

6 RevisedAugust26,2009InitialCertificationApplication Page3 CareerandTechnicalEducation(CTE)Majors(selectonebox): Business,Management,MarketingandTechnology(BMMT) HealthOccupations Marketing TradeandIndustry VocationalCertificationisrequiredforallCTEMajors TheInterimOccupationCertificate(IOC)(selectonebox): IhaveaVocationalCertificate:Attachacopyofyourcurrentcertificate(required). IamapplyingforanInterimOccupationalCertificate.YoumustsubmityournotarizedCertificateof Experienceform( approval. PUBLICACT18of2003Sec.1531d. CertificationinFirstAidandAdultandChildCPR PersonsseekinganinitialteachingcertificatemustholdvalidcertificationinFirstAidandAdultandChild CardiopulmonaryResuscitation(CPR). AreyoucertifiedinFirstAid? YES NO AreyoucertifiedinAdultCPR? YES NO AreyoucertifiedinChildCPR? YES NO Ifyouanswered no toanyoftheabovequestions,whenwillcertificationbecompleted: Date FirstAidandAdult/ChildCPRcertificationmustbefromanorganizationapprovedbytheMichiganDepartmentof Education.AlistofapprovedorganizationsmaybefoundonourCertificationWebsite: Race:Pleaseidentifyyourracial/ethnicbackground(checkoneboxonly). Evenifyouaremultiracial,pleaseselectoneboxbyindicatingeithertheraceyouidentifywiththemostorthe racewithwhichyouareusuallyassociatedinthecommunity. AmericanIndian,Eskimo,orAleut AsianorPacificIslander Black(non"Hispanic) Hispanic White(non"Hispanic) Areyoumultiracial?Forpurposesofthisquestion,youaremultiracialifyouhaveparentsfrommorethanoneof thebroadracecategorieslistedabove,orifyourparentsregardthemselvesasbeingmultiracial. YES NO Youmustpresentyoursigned certificationcardstoacademic Servicesforverification.

7 RevisedAugust26,2009InitialCertificationApplication Page4 ConvictionandRevocationInformation Please answer the three questions listed below and read the following information(completion of this section is required). 1.Haveyoueverbeenconvictedofafelony? YES NO 2.Haveyoueverbeenconvictedofanyotheroffense? YES NO 3.Haveyoueverhadaprofessionallicenseorcertification, denied,suspended(forcause)orrevoked? YES NO If you answer yes to any of the questions regarding convictions and revocations, attach a current (within 6 monthsoftheapplicationdate)statewidecriminalhistorycheckfromtheinternetcriminalhistoryaccesstool (ICHAT)website: A JudgmentofSentence foranyconvictionmustbeonfilewithyourapplicationforthecollegeofeducationto recommend you for teacher certification to the Michigan Department of Education. This document may be obtainedfromthecourtwherethematterwasadjudicated.inaddition,anarrativedescribingthecircumstances surroundingtheconvictionoractionfromyourperspectivemustbeonfile. Uponapprovalofyourapplication,a90"DayCertificationLetterwillNOTbeissuedasmandatedbytheMichigan DepartmentofEducation. StateBoardofEducationTeacherCertificateCode:R Certificates;denial,suspension,orrevocation. (1) Thesuperintendentofpublicinstructionmayrefusetograntorrenew,ormaysuspendforafixedterm,or revoke,ormayimposereasonableconditionson,ateachingcertificateorstateboardapprovalgranted pursuanttotheserulesforthefollowingreasons: (a) Fraud,ormaterialmisrepresentation,concealmentoromissionoffactintheapplicationfor,orthe useof,ateachingcertificateorstateboardapproval. (b) ConvictionofanoffenselistedinMCL aorMCL b. (2) Thesuperintendentofpublicinstructionmayrefusetograntorrenewateachingcertificateorastateboard approvalforfailureorineligibilityoftheapplicanttomeetthecriteriafortheapplicablecertificationorstate boardapproval. Acknowledgment&Consent Iaffirmthattheinformationprovidedinthisapplicationistrue,complete,andaccurate,andIherebygrant permissionforcollegeofficialstoreleaseinformationconcerningmydegreeandcertificationtopotential employersandcertificationagencies. Applicant ssignature Date The Administrative Rules Governing Certification require that an application for certification must be madenolaterthanfiveyearsafterrequirementshavebeenmet.

8 RevisedAugust26,2009InitialCertificationApplication Page5 RequiredDocumentation"ThefollowingdocumentsMUSTbesubmittedwiththisapplication: Checktheboxacknowledgingtherequirement. Subject"AreaTestscoresfortheMichiganTestforTeacherCertification Testscoresarerequiredforallsubjectareasinwhichyouareseekingcertification. Apassingscoreonasubject"areatestwillremainvalidforaperiodoffive(5)years.Afterfiveyearshaveelapsed andifacertificateorendorsementhasnotyetbeenissued,ateachercandidateforcertificationwillberequired toretakethetestuntilapassingscoreisachieved. Ifyoursubject"areaexaminationscoreswerenotreleasedtoWayneStateUniversity,pleaserequestanoriginal score report from Evaluation Systems Group of Pearson. From the Score Reporting link on the MTTC website ( your scores sent to Wayne State University(31). Your scores must be mailed directly from Evaluation Systems GroupofPearsontoWayneStateUniversity.AnoriginalscorereportisrequiredbytheMichiganDepartmentof Educationforverificationoftestscores. AsignedPlanofWorkreflectingyourcurrentprogram UnofficialcopiesoftranscriptsforcoursescompletedoutsideofWayneStateUniversity Acurrent(within6monthsoftheapplicationdate)CriminalHistoryCheck CurrentFirstAidandAdult/ChildCPRCertificationcards(presentyoursignedcertification cardstoacademicservicesforverification) SubmitthisapplicationwiththeabovedocumentationtotheCertificationOffice,WayneStateUniversity, 469Education,Detroit,Michigan48202,Phone:(313)577"1601,Fax:(313)577"4944 """""""""""""""""""DONOTWRITEBELOWTHISLINE FOROFFICEUSEONLY"""""""""""""""""" CurrentGPA: DistinctionStatus CumLaude* MagnaCumLaude** SummaCumLaude*** EducationDegree: BachelorofArts BachelorofScience OtherDegree: GraduationDate: StateRequirements: FirstAid AdultCPR ChildCPR CriminalHistoryCheck ProvisionalCertificate: Elementary Secondary ForeignLanguage: OPI BBE: OPI WPT VocationalCertificate: InterimOccupationCertificate: Major: Major: Minor: Minor: Endorsement(s): Notes: SignatureofAcademicServicesOfficer Date SpecialProcessing: JudgmentofSentenceRequiredtoRoster RosterSeparately No90"DayLetter