A completed Conduct Review Statement must accompany every application (including renewal).

Educator Licensing 1500 Highway 36 West Roseville, MN 55113-4266 APPLICATION FOR MINNESOTA EDUCATION LICENSE (LIMITED OR NRENEWABLE) 1. FILE FOLDER NUMBER GENERAL INFORMATION AND INSTRUCTIONS: A partial If you hold a Minnesota or incomplete application packet will be returned to the applicant for Education License, enter the completion and resubmission. It is the applicant s responsibility to number here. submit the required items in one envelope to Educator Licensing. To ensure the submission of a complete packet, review and follow the attached checklist. If you have questions, call 651-582-8691 or go to the Web site: http://education.state.mn.us FOR STATE USE ONLY REGISTER NUMBER A check or money order payable to COMMISSIONER OF MDE must be included: $83.25 for an initial application that includes a fingerprint card; $57 for all other applications. This is a non-refundable processing fee. 2. APPLICATION TYPE Check one: Complete Sections: Limited full time license initial renewal 3, 4, 5 Teacher School Counselor School Psychologist Speech-Language Pathologist Career and Technical Fields 3, 4, 5, 6* (*section 6 for initial under 8710.8010-8710.8080) Check one: Complete Sections: Limited short call substitute teacher license 3, 4, 8 (2 year license) Nonrenewable Teacher License 3, 4, 9 (3 year license) Limited intern license 3, 4, 7 A completed Conduct Review Statement must accompany every application (including renewal). 3. APPLICANT INFORMATION It is not mandatory to provide your Social Security Number. Failure to do so may result in misidentification, but will not result in the denial of a license. Last Name First Name Middle Name Previous Name Social Security Number Month/Day/Year of Birth Gender Daytime M F - - Home Address: Street City State Zip Code 4. EDUCATIONAL BACKGROUND COLLEGE OR UNIVERSITY To be completed for all applications. Use the codes at the right. LOCATED AT: (City and State) DEGREE CODE 2 = Bachelor 3 = 5 Yr. Program 4 = Master YEAR OF DEGREE 5 = Specialist 6 = Doctorate For State Use Only COLLEGE CODE

APPLICATION FOR MINNESOTA EDUCATION LICENSE (Limited or Nonrenewable) Page Two 5. LIMITED FULL-TIME LICENSE INFORMATION / DISTRICT VERIFICATION Note: For Limited Career and Technical Licensure, see Education License Application Information for more information. 1. Proposed Subject/ Field of Assignment: Grade Level: School Year: 2. As the designated administrator of the employing school district or charter school, my signature verifies the following: No applicant holding a teaching license in the subject or field requested can fulfill the requirements of the position; The position has been advertised, and if the position is one-half time or more, the position has been advertised statewide; The district/charter school will provide a mentor to give support and assistance to the individual; The applicant holds a baccalaureate degree from a college or university accredited by the regional association for the accreditation of colleges and secondary schools; and The applicant has completed a college or university degree with at least a minor in the area for which the limited license is requested, or has a degree directly related to the professional practice for which speech-language pathology, school psychologist, or school counselor licensure is requested, and other required documentation for these fields is provided with this application or has already been submitted to Educator Licensing. 3. I verify that the information provided on this application is correct. Print Name of Superintendent/Charter School Administrator District Name - Six Digit District Number Signature of Superintendent/Charter School Administrator - - 6. EMPLOYMENT/EXPERIENCE FOR LIMITED CAREER AND TECHNICAL LICENSURE For a limited license in Career and Technical fields under parts 8710.8010 through 8710.8080, the hiring district or charter school must verify that the individual has completed specific training for and at least four years of full-time employment or the equivalent in an occupation of the employment field for which the limited license is sought. Please use a separate line to verify training and employment experiences. Do not include leaves-of-absence. Place of Employment or Where Experience was Earned State From: s of Service To: If Not Full-Time, Indicate % of Full-Time Grade & Subjects Taught or Position Title if Non-Teaching I confirm that this information is true and correct. Print Name of Authorized Official Title Signature of Authorized Official - - Name of School District/Employer City State and Zip Code

APPLICATION FOR MINNESOTA EDUCATION LICENSE (Limited or Nonrenewable) Page Three 7. LIMITED INTERN LICENSE INFORMATION / DISTRICT AND COLLEGE/UNIVERSITY VERIFICATION Proposed Subject/ Field of Assignment: I support this application for limited intern licensure and hereby verify: Grade Level: School Year: that the intern position is designed to serve as a learning experience for a college or university student who is completing a preparation program leading to Board of Teaching licensure; the intern will be assigned to assist a licensed teacher or other education professional licensed by the Board of Teaching whose students are the responsibility of the licensed teacher or other licensed professional; the intern will serve under the direct day-to-day supervision of a licensed teacher or other education professional licensed by the Board of Teaching, and will not serve as the classroom teacher or other education professional for students; and the intern will not replace a licensed teacher or other licensed professional. I verify that the information provided on this application is correct. Print Name of Superintendent/Charter School Administrator District Name - Six Digit District Number Signature of Superintendent/Charter School Administrator - - I verify that 1) the applicant is currently enrolled in an approved preparation program leading to Board of Teaching licensure and has completed at least three years of preparation required for the license, and 2) the college or university will assist in designing the learning experience and will provide supervision of the intern during the learning experience. Print Name of College/University Certification Officer College/University Name - - Signature of Certification Officer 8. LIMITED SHORT-CALL SUBSTITUTE TEACHER LICENSE DISTRICT VERIFICATION I support this application for a limited short-call substitute teacher license. The district has advertised in good faith for regularly licensed teachers to serve as short-call substitute teachers but has been unable to secure a sufficient number of regularly licensed teachers to meet the district s short-call substitute needs. I hereby verify that the information provided on this application is correct. Print Name of Superintendent/Charter School Administrator District Name - Six Digit District Number Signature of Superintendent/Charter School Administrator - -

APPLICATION FOR MINNESOTA EDUCATION LICENSE Page Four 9. NRENEWABLE TEACHER LICENSE INFORMATION / DISTRICT VERIFICATION Proposed Subject/ Field of Assignment: Grade Level: 1. As the designated administrator, my signature verifies the following: The teacher holds a current valid Minnesota professional license granted by the Board of Teaching; Reasonable efforts have been made to assign existing staff to fill the position with a fully licensed teacher; No applicant holding a teaching license in the subject or field requested can fulfill the requirements of the position; and The position has been advertised, and if the position is one-half time or more, the position has been advertised statewide. If the subject/field of assignment is a core academic subject, the teacher meets federal highly qualified teacher requirements as identified in the Minnesota State Plan For Federal Highly Qualified Teacher Requirements. (Appropriate documentation must be maintained by the district.) (For special education assignment, see Note on page 2 of Limited or Nonrenewable Education License Application Information.) The district will provide for: - a high quality professional development plan for the teacher that is sustained and classroom-focused, and - ongoing support for the teacher or a teacher mentoring program. The teacher understands the criteria of the assignment and is in an approved course of study for this subject, or there is evidence to demonstrate the teacher is making application for an approved course of study for this subject. I hereby verify that the information provided on this application is correct. Print Name of Superintendent/Charter School Administrator District Name - Six Digit District Number Signature of Superintendent/Charter School Administrator - - I am aware of this request for a nonrenewable license for me, which, if granted, will authorize me to teach in the above subject for which I am not currently licensed. Signature of Teacher

APPLICATION FOR MINNESOTA EDUCATION LICENSE CONDUCT REVIEW STATEMENT Page Five IDENTIFICATION INFORMATION Applicant Full Name (Last, First, Middle) Previous Full Name File Folder Number Social Security Number of Birth (mm/dd/yy) FOR STATE USE ONLY It is not mandatory to provide your Social Security Number. Failure to do so may result in misidentification but will not result in the denial of a license. Place either an X or a checkmark in the appropriate boxes below. If there is any writing on this form it cannot be scanned properly and your application will be delayed. If you are submitting additional information, you must use either page six (6) or other sheets of paper. You must answer all questions completely and provide all requested information. (If this is not your first application for a Minnesota education license, your answers on this conduct review statement apply only to the period since your last application. If you answered yes to any of these questions on previous applications and supplied supplemental information, it is not necessary to do so again.) 1. Have you ever been convicted of a crime? For purposes of this question, the term crime includes a misdemeanor, a gross misdemeanor, a felony or a charge that resulted in a stay of imposition of sentence. (DWI s and DUI s are included in this definition and should be disclosed.) (DO T INCLUDE PETTY MISDEMEARS.) The term conviction includes a finding of guilty by a jury or judge, an admission of guilt or plea of guilty, or any no contest or Alford plea (a plea without an admission of guilt). You are considered convicted whether the sentence is stayed or executed. YES - If you answered yes, you must complete the Supplemental Information page [page six (6) of this application form] for each conviction, and attach it to this page. 2. Have you ever been referred to a pre-trial diversion program after being arrested? YES - If you answered yes, you must attach material explaining the action, location(s), date(s), and the agency involved. 3. Have you ever been acquitted or found not guilty of a criminal offense involving sexual conduct, homicide, assault, or any other crime involving violence? YES - If you answered yes, you must attach material explaining the offense, date, location, and the law enforcement agency involved. 4. Are any criminal charges currently pending against you in Minnesota or any other state? YES - If you answered yes, you must complete and attach page six (6) of this form, the Supplemental Information form. 5. Have you ever had an education or other occupational license revoked, suspended, or denied in Minnesota or in any other state? YES - If you answered yes, you must attach material explaining the type of license, the date action was taken, and the agency involved. 6. Have you ever voluntarily surrendered an education or other occupational license? YES - If you answered yes, you must attach material explaining the action, location, date, and the agency involved.

APPLICATION FOR MINNESOTA EDUCATION LICENSE Page Six CONDUCT REVIEW STATEMENT, continued 7. Is disciplinary action against your teaching, administrative, or other occupational license currently pending in another state? YES - If you answered yes, you must attach material explaining the action or charges, location, date, and agency involved. 8. Have you ever resigned from or otherwise left any employment after allegations of misconduct were made against you or when an investigation into those allegations was pending? YES - If you answered yes, you must attach material explaining the action or charges, location, date, and employer involved. 9. Have you or a school district in which you were employed ever been a party to a civil settlement, award or agreement of any kind that involved an allegation that involved your sexual conduct? YES - If you answered yes, you must attach material explaining the situation including date and location of the school district. WARNING: FAILURE TO ANSWER ANY OF THE ABOVE QUESTIONS IN A TRUTHFUL MANNER OR FAILURE TO PROVIDE THE INFORMATION REQUESTED COULD LEAD TO DENIAL OR DISCIPLINARY ACTION BEING TAKEN AGAINST ANY TEACHING OR SCHOOL ADMINISTRATIVE LICENSE. CERTIFICATION OF INFORMATION I certify that all information contained on and submitted with this application is to the best of my knowledge true and accurate. I understand that misrepresentation of facts or falsification of statements or accompanying documents may result in denial of licensure and could affect the status of my other teaching or school administrative licenses. Signature of Applicant Complete the next page only if you answered yes to question 1 or 4.

APPLICATION FOR MINNESOTA EDUCATION LICENSE Page Seven CONDUCT REVIEW STATEMENT, continued Complete this page only if you answered yes to question 1 or 4 on page four (4) of this form. APPLICANT CONVICTION/OUTSTANDING CHARGE INFORMATION PLEASE COMPLETE A SEPARATE FORM FOR EACH CONVICTION OR OUTSTANDING CHARGE. YOU MAY PHOTOCOPY THIS FORM. 1. Convicted or currently charged with: 2. Level of offense (check one): Felony Gross Misdemeanor Misdemeanor 3. of offense: 4. Name of arresting agency (police, county sheriff, etc.): 5. Court Jurisdiction (i.e., Hennepin County District Court, Mpls., MN): 6. Plea and conditions of probation, if any: 7. of release from probation: 8. If still on probation, name and telephone number of probation officer: Name - - 9. Details of the incident: VERIFICATION/AUTHORIZATION OF INFORMATION I verify the foregoing information is true and correct. I hereby authorize the above listed courts and law enforcement agencies to release any information concerning me to the Minnesota Board of Teaching. Printed Name of Birth Signature

MINNESOTA DEPARTMENT OF EDUCATION (MDE) Educator Licensing 1500 Highway 36 West Roseville, MN 55113-4266 651-582-8691 FAX 651-582-8809 WEB: http://education.state.mn.us e-mail: mde.educator-licensing@state.mn.us Limited or Nonrenewable Education License Application (ED-02395-03) Information Limited full time license Applications for limited licenses are accepted on or after July 1 for the forthcoming school year. A limited license is valid for use in the requesting school district or charter school only and is issued for one school year or a portion of a school year from the date of issuance to the following June 30. If the requesting school district or charter school offers summer school or extended school year services, a limited license that expires on June 30 is valid for the summer in the year of expiration of the license. Minnesota Rule 8710.1250 specifies that no more than three limited licenses can be granted to an individual, except under 8710.1250, subpart 2a, that pertains to specific Career and Technical licensure fields. A limited full time license permits a person to teach/provide related service in an area for which the person has not completed an approved preparation program. A limited full time license is granted or renewed twice if the following conditions are met: 1. The designated administrator of the employing public school district or charter school requests a limited full time license; and 2. The designated administrator of the employing public school district or charter school verifies that a. no applicant holding a license in the subject or field for which the temporary license is requested can fulfill the requirements of the position; b. the position has been advertised, and if the position is one-half time or more, the position has been advertised statewide; c. the school district or charter school will provide a mentor to give support and assistance in necessary skill development; d. the applicant holds a baccalaureate degree from a college or university accredited by the regional association for the accreditation of colleges and secondary schools; and e. the applicant has completed a college/university degree with at least a minor in the area for which teacher licensure is requested, or a degree directly related to the professional preparation for which speech-language pathologist, school psychologist, or school counselor limited licensure is requested. Note: For an initial limited license in any Career and Technical field, the requirements stated above in items 1 and 2 must be met. However, if the applicant does not have a baccalaureate degree, and is seeking licensure under rules 8710.8010 through 8710.8080, an initial limited license may be issued when the hiring district or charter school provides verification in section 6 of completion of specific training for, and at least four years of full-time employment in, the proposed field of licensure. Under this option the provisions specified above in item 1 and item 2 a-c must also be met. Those who hold a limited license that was initially granted based on a baccalaureate degree may renew up to two times by following steps stated above in items 1 and 2. Those who hold a limited license without a baccalaureate degree may renew up to four times and must attach to the application an official transcript, in a college/university sealed envelope, showing completion of eight (8)semester credits earned in the last year in an approved licensure program. Items 1 and 2 a-c above must also be met. Minnesota teacher education graduates who have completed a baccalaureate degree and have met all requirements for full licensure except for achieving passing scores on the Praxis examinations are eligible for limited full time licensure. In addition to meeting the conditions of item 2 a-e above, the application materials must include either an original score report or written confirmation from the dean/chair of teacher education that all requirements for full licensure have been met with the exception of the required examinations. Section 5 must be completed, signed, and dated by the district superintendent/charter school administrator. Limited intern license A limited intern license permits a person to serve as an intern under the direct supervision of a licensed teacher or, for a related service, an educational professional licensed in that field by the Board of Teaching, for the equivalent of no more than one school year while completing an internship in a preparation program leading to Board of Teaching licensure. The limited intern license does not authorize the intern to serve as a teacher or other authorized professional. The intern must be currently enrolled in an approved preparation program leading to Board of Teaching licensure and have completed at least three years of the preparation required for the license. The college/university must assist in designing the learning experience and provide supervision of the intern during the learning experience. (continued next page)

Minnesota Department of Education - Educator Licensing Limited or Nonrenewable Application Information, continued page 2 A limited intern license may be renewed once, upon application, if additional time is needed for the intern to complete the equivalent of one school year of internship experience. Section 7 must be completed, signed and dated by the school district superintendent/charter school administrator and the certification officer/registrar of the college/university through which the applicant is completing the state approved licensure program and which will subsequently be providing the required supervision throughout the internship experience. Limited short call substitute teacher license A short call substitute teacher is one who teaches on a day-to-day basis not to exceed 15 consecutive days replacing the same teacher. A short call substitute teacher must hold a Minnesota full time teaching license or a short call substitute teacher license. The short call substitute teacher license is valid for short call substitute teaching at all grade levels in all subjects. Note: A long call substitute teacher is one who replaces the same teacher for 16 or more consecutive days. A long call substitute teacher must hold a full professional license or Board of Teaching permission to teach in each licensure area taught. A limited short call substitute teacher license expires two years from the June 30 nearest the date the license is issued. A limited short call substitute teacher license shall be granted to an applicant if the following conditions are met: 1. the designated administrator of an employing school district or charter school requests a temporary limited short call substitute teacher license; 2. the designated administrator of an employing school district or charter school verifies in writing (section 8) that the school district or charter school is experiencing hardship in securing a sufficient number of licensed teachers to meet the need for short call substitute teachers; and 3. the applicant holds a baccalaureate degree from a United States college or university, or the equivalent. Nonrenewable teacher license A nonrenewable teacher license permits a licensed teacher to teach in a subject for which the teacher is not currently licensed. Applications for nonrenewable teacher licenses are accepted on or after July 1 preceding the first school year for which the license is requested. A nonrenewable teacher license is valid for three school years from the date of state approval to the end of the third school year, June 30. If the requesting school district or charter school offers summer school or extended school year services, a nonrenewable teacher license that expires on June 30 is valid through the summer in the year of expiration of the license. A nonrenewable teacher license is granted for use in the requesting school district or charter school if the following conditions are met: 1. The designated administrator of the employing public school district or charter school requests a nonrenewable license; and 2. The designated administrator of the employing public school district or charter school verifies in writing that a. reasonable efforts have been made to assign existing staff to fill the position with a fully licensed teacher; b. no applicant holding a teaching license in the subject can fulfill the requirements of the position; c. the position has been advertised, and if the position is one-half time or more, the position has been advertised statewide; d. the administrator on behalf of the licensed teacher will use the High Objective Uniform State Standard of Evaluation (HOUSSE) and those criteria as necessary and proper to demonstrate subject matter competence in the nonlicensed area as established by the Board of Teaching, and that the teacher meets the Board s criteria; * e. the district or charter school will provide for a high quality professional development plan for the teacher that is sustained and classroom-focused before and while teaching, and will provide ongoing support for the teacher or a teacher mentoring program; f. the teacher is in an approved course of study and will complete the approved program by the end of the third school year; g. the teacher holds a current valid Minnesota professional license granted by the Board of Teaching; and h. the teacher understands the criteria of the assignment and is in an approved course of study or there is evidence to demonstrate the teacher is making application for an approved course of study. * Note: A nonrenewable license may be granted for special education licensure fields. However, in order to be considered highly qualified, a special education teacher must at a minimum hold a bachelor s degree and have been granted full licensure in another special education field. In accordance with the reauthorization of the Individuals with Disabilities Act (IDEA 2004), a teacher without full licensure in another special education field cannot meet federal highly qualified requirements. A nonrenewable teacher license shall not be granted to a teacher holding a temporary limited license and shall not be granted to speech-language pathologists, school counselors, school nurses, school psychologists, or school social workers.

Minnesota Department of Education - Educator Licensing Limited or Nonrenewable Application Information, continued page 3 Other information Additional licensure information is available at http://education.state.mn.us. Privacy Statement The data you furnish on and with the Application for Minnesota Education License (Limited or Nonrenewable) will be used by the Minnesota Department of Education and the Minnesota Board of Teaching (licensing authority) to assess the applicant s qualifications for licensure. You are not legally required to provide this data; however, if you fail to do so, the agencies may be unable to process the license application for which the data is required. Until licensure is granted, the information in the application is private data, accessible only to you, the Minnesota Department of Education and the Minnesota Board of Teaching, its agents, and/or agents of the Attorney General s Office representing the Minnesota Department of Education and the Minnesota Board of Teaching. This file becomes public record if licensure is granted, except that your social security number and home address remain private, subject to disclosure requirements as follows: Social Security Number Information - Pursuant to Minnesota Statute 270.72 Tax Clearance: Issuance of Licenses, the licensing authority is required to provide to the Minnesota Commissioner of Revenue your social security number. This information may be used to deny the issuance, renewal or transfer of your license in the event you owe the Minnesota Department of Revenue delinquent taxes, penalties or interest. Upon receiving the information, the licensing authority will supply it only to the Minnesota Department of Revenue; however, under the Federal Exchange of Information Agreement, the Department of Revenue may supply this information to the Internal Revenue Service. Failure to supply this information may jeopardize or delay the processing of your licensing issuance or renewal application. In conjunction with required data reporting from Minnesota public school districts, the licensing authority will only use private or confidential data for purposes of confirming unique identity. Persons having access to the data at the Minnesota Department of Education are only those working directly with Licensing or the data reporting systems.

MINNESOTA DEPARTMENT OF EDUCATION (MDE) Educator Licensing 1500 Highway 36 West Roseville, MN 55113-4266 651-582-8691 FAX 651-582-8809 WEB: http://education.state.mn.us e-mail: mde.educator-licensing@state.mn.us Only a complete application packet will be accepted for processing. A partial or incomplete submission (pages, signatures, transcripts, fees or other relevant information missing) will be returned to the applicant for completion and resubmission. It is the applicant s responsibility to collect the items needed for evaluation for licensure and submit them in one envelope to Educator Licensing. Original transcripts must be submitted in a college/university-sealed envelope. Please do not request that items (transcripts, etc.) be sent directly to Educator Licensing. To ensure the submission of a complete packet, review and follow the checklist items. Note: All applications for Limited or Nonrenewable licensure are accepted on or after July 1 for the coming school year. COMPLETE PACKET SUBMISSION CHECKLIST For ALL applications, please submit: A completed license application form, including the conduct review statement pages, with required signatures and dates in the appropriate section of the form. For all applications, complete sections 2, 3 and 4. A personal check, money order, or cashier s check made payable to the Commissioner of MDE must be included with your application: $83.25 for an initial application, or $57 for all other applications. If submitting a money order, but sure to sign it. This is a non-refundable processing fee and will not be returned to an applicant who does not qualify for licensure. For ALL initial Limited, Limited Intern, and Limited Short Term SubstituteTeacher license applications, please submit: A completed and signed Minnesota Department of Education fingerprint card. Minnesota state law requires that all candidates applying for initial licensure in this state be fingerprinted for a national criminal background check. The fingerprinting must be done at a law enforcement agency in black on a card supplied by the Educator Licensing office. You may be charged a separate fee for this service. Provide all required personal information, but do not make other marks or highlighting on the card. Do not bend or fold the card. This background check is for state use only. College/university transcripts (undergraduate and graduate) from all institutions attended in the unopened college/universitysealed envelope. Applicants prepared outside the United States or its territories must submit the original course-by-course foreign credential evaluation report. A list of authorized evaluation services is available from the Educator Licensing office. For both initial and renewal Limited, Limited Intern, and Limited Short Term Substitute license applications, The appropriate section, 5, 7, or 8 must be completed, signed, and dated by the district superintendent/charter school administrator. A limited intern license application also requires, in section 7, the signature of certification officer/registrar of the college/university through which the applicant is completing the state approved licensure program. For a Limited license in any Career and Technical field: An applicant without a baccalaureate degree seeking initial licensure in any field under 8710.8010 through 8710.8080 must provide district verification, in section 6, of specific training for, and at least four years of full-time employment in, the proposed field of licensure. An applicant without a baccalaureate degree who is renewing any field under 8710.8010 through 8710.8080 must attach an official transcript in the unopened college/university-sealed envelope verifying eight (8) semester credits earned in the last year within an approved career and technical licensure program. For ALL Nonrenewable Teacher license applications: Section 9 requires the signature of the district superintendent/charter school administrator. The signature of the teacher verifies the teacher understands the criteria of the assignment and the request for a nonrenewable license. Additional licensure information is available at http://education.state.mn.us