How to Apply
VERIFICATION BY INSTITUTION: COMPLETION OF APPROVED EDUCATION PROGRAM
How to Apply
Applicant: ? Fill in current personal information (please print or type).
Approved Educator Preparation Program Dean/Associate Dean or Licensure Officer: ? Complete one (1) of the boxes in the center section of this form ? Check the regional accreditation, state approval and program requirement boxes at the bottom of this form ? Sign form verifying the above ? Include email address
Submitting the form: ? Submit a completed copy of Form V, along with all other required documentation and evaluation fees, online at . Application instructions and additional information are available within the online licensure system.
Form V August 2019
VERIFICATION BY INSTITUTION:
COMPLETION OF APPROVED EDUCATION PROGRAM
TO THE APPLICANT: Fill in the information above the line. Please type or print.
last name
first name
middle name
maiden name
street address
city
state
zip code
social security number
TO THE DESIGNATED COLLEGE OFFICIAL: Fill in ONE of the boxes and BOTH sections at the bottom of the page.
The applicant completed requirements for the
bachelor's
master's
six year (educational specialist)
doctorate
degree and finished an approved education program in the licensure area(s) of (e.g. elementary education, music, secondary mathematics, etc. as stated on lines below)
The applicant did not earn a degree from this institution but completed an approved education program at the degree level of
bachelor's
master's
six year (educational specialist)
doctorate
in the area(s) of (e.g. elementary education, music, secondary mathematics, etc. as stated on lines below)
Date program completed month, day, year
Date program completed month, day, year
The program completed meets the following accreditation, approval, or program requirements (check all that apply):
National Council for Accreditation of Teacher Education (NCATE/TEAC/CAEP)
National Association of State Directors of Teacher Education and Certification Standards (NASDTEC)
Education program approval by the state of
Regional accreditation by (name of body)
The applicant completed an education program approved in the area(s) and at the level(s) recommended. The approved program was in effect during the applicant's period of study.
name of institution
designated official (licensure officer, dean of education)
title
signature
date
email address
Form V August 2019
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