PDF Kansas State Department of Education

Kansas State Department of Education Teacher Licensure and Accreditation

900 SW Jackson Street, Suite 106, Topeka, KS 66612-1212

Phone: 785-296-2288

FORM

3b



Upgrade Information

Upgrading a two-year exchange, one-year nonrenewable or transitional (out-of-state) license

Two Year Exchange Certificate/License

Verification of completion of any deficiencies in pre-standard certification/licensure requirements:

Successful completion of the required Kansas pre-standard certification/licensure tests: Principles of Learning and Teaching (PLT) Test and/or appropriate content assessment(s).

and/or Recency:

a. Recent experience-verification of one (1) year of accredited experience within the six-year period prior to application for renewal. This requirement may be met by teaching under contract one year in an accredited school (not necessarily in Kansas) during the validity of your exchange certificate/license. or

b. Recent credit ? Semester credit hours from a regionally accredited college or university that are not older than six years old at the time you apply to upgrade to the full certificate/license.

and/or Minimum cumulative grade point average of 2.5 on a 4.0 scale. and/or Any other described deficiency.

The exchange certificate/license is available ONLY once. Deficiencies MUST be completed so that the applicant can move the full certificate/license.

One Year Non-Renewable

Verification of completion of the pre-standard certification/licensure testing requirement(s):

Successful completion of the Principles of Learning and Teaching (PLT) Test and/or appropriate content assessment(s).

This certificate/license is available ONLY once. Deficiencies MUST be completed so that the applicant can move to the full certificate/license.

Form 3b ? Upgrade Exchange TN and EX

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Revised 12-15

Kansas State Department of Education Teacher Licensure and Accreditation

900 SW Jackson ST, Suite 106, Topeka, KS 66612-1212

Phone: 785-296-2288

Application Instructions



1. Complete all sections on the front page of the application.

2. Complete those sections of the application that pertain to your basis for renewal.

3. Include one or more of the following to document your basis for renewal:

Applications received without official documentation attached will be sent back to the applicant.

a.

Official college/university transcripts in the sealed envelope from the college/university to verify semester credit

hours. Do not have transcripts sent directly to KSDE.

b.

Verification of passing scores on appropriate tests:

Attach an official score report

OR

I selected the code for KSDE as a score recipient for my scores when I registered

OR

If unable to verify official scores based on one of the above, you will need to log onto the ETS website and select

KSDE as a score recipient OR a university may provide you with a verification of you scores if you coded the

university as a score recipient.

c. Experience verification form in a sealed envelope to verify accredited experience.

4. Include a personal check or money order in the amount of $60.00.

Do not combine this fee with the background fee if you are submitting fingerprints.

5. Determine if you need to submit fingerprints:

Items to note: ? If you have earned a new degree, an official degree transcript must be submitted, regardless of the basis for renewal. ? Any out-of-state accredited experience must be accompanied by a copy of the out-of-state certificate/license valid during verified experience.

Form 3b ? Upgrade Exchange TN and EX

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Revised 12-15

APPLICATION FOR KANSAS UPGRADE OF ONE-YEAR

NON-RENEWABLE TWO-YEAR EXCHANGE

TRANSITIONAL (OUT-OF-STATE)

FORM

3b

SECTION A ? TO BE COMPLETED BY APPLICANT I. VITAL INFORMATION

1. Social Security Number

-

-

2. Legal Name

(First)

(Middle)

KSDE USE ONLY

Sign Fee Expire RAP M&E Walk-in

Legal

FP In Sendback Verified by

(Last)

Consultant

3. Mailing Address

City

State

Zip Code

4. Birthdate (MM/DD/YYYY) 5. Gender Male

6. Phone:

-

-

Female

Alternate Phone:

-

-

7. a. List all prior names (maiden, alias, previous married, etc.) _______________________________________________________________

b. Effective and expiration dates of last certificate: ___________________________________ to ___________________________________

c. Verify all degrees earned: (example: BA, MS, EDS, etc.)

Institution:_________________ Degree:__________ Year Earned:________ Institution:_________________ Degree:__________ Year Earned:________

Institution:_________________ Degree:__________ Year Earned:________ Institution:_________________ Degree:__________ Year Earned:________

8. Ethnicity (Mark only if applicable) Hispanic/Latino

9. Race (Choose one or more) American Indian or Alaska Native

Black or African American

White

Asian

Native Hawaiian or Other Pacific Islander

Refuse to Designate

10. Have you honorably served in any branch of the US Armed Forces, including the National Guard and Reserves? No Yes

If Yes, please enter total years below in a and b.

a. Total years of active duty service in any branch of the US Armed Forces (if none enter "0")

_____________________________

b. Total years of national guard/reserve service (if none enter "0")

____________________________

11. Email Address (Please provide an email address that will be active throughout the application process so that we may notify you of the changing

status of your application.)

______________________________________________________________________________________

Please read the following questions very carefully. Failure to accurately answer these questions or submit appropriate documents will delay

the issuance of your license. Unless expunged, you are required to disclose both adult and juvenile offenses.

12. a. Have you EVER been convicted of a felony?

NO

YES If yes, please attach a certified copy of the charging document and of the journal entry of conviction.

b. Have you EVER been convicted of ANY crime involving theft, drugs, or a child?

NO

YES If yes, please attach a certified copy of the charging document and of the journal entry of conviction.

c. Have you EVER entered into a diversion agreement or otherwise had a prosecution diverted after being charged with any felony or

any crime involving theft, drugs, or a child?

NO

YES If yes, please attach a certified copy of the charging document, the diversion agreement, and the journal entry

closing that case.

d. Are criminal charges pending against you in any state involving any felony or any crime involving theft, drugs, or a child?

NO

YES If yes, please attach a certified copy of the charging document.

e. Have you had a teacher's or school administrator's certificate or license denied, suspended, revoked or been the subject of other

disciplinary action in any state?

NO

YES If yes, please indicate the action taken: denied, suspended or revoked.

Which state(s)?

Please attach a copy of the documents regarding the official action taken.

f. Is disciplinary action pending against you in any state regarding a teacher's or administrator's certificate or license?

NO

YES If yes, please attach a copy of the official documents regarding the action pending against you.

g. Have you ever been disbarred or had a professional license or state issued certificate denied, suspended, revoked or been the subject

of other disciplinary action regarding any profession in Kansas or any other state?

NO

YES If yes, please indicate the action taken: denied, suspended or revoked.

Which state(s)?

Please attach a copy of the documents regarding the official action taken.

Form 3b ? Upgrade Exchange TN and EX

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Revised 12-15

h. Have you ever been terminated, suspended, or otherwise disciplined by a local Board of Education for falsifying or altering student

tests or student test scores?

NO

YES If yes, which district(s)?

When?

i. Have you ever falsified or altered assessment data, documents, or test score reports required for licensure?

NO

YES If yes, what state(s)?

When?

13. I certify that I am of good moral character and that the information on this application is true and complete to the best of my knowledge. I understand that any misrepresentation of facts may result in the denial or revocation of my certificate/license.

I hereby grant the permission and authorize the Kansas State Department of Education to verify all responses with any mental health facility or governmental agency and to obtain and review all records maintained by any criminal justice agency, including a criminal history record information check, regarding any of my criminal charges, adjudications, or convictions, and to contact previous employers for information regarding the term of my employment. I hereby release, discharge, and exonerate the Kansas State Department of Education, its employees, and any person so furnishing information from any and all liability of every nature and kind arising out of the furnishing of such records and information. I understand that any material submitted in connection with this application will become the property of the Kansas State Department of Education, and may be considered a public record.

Signature of Applicant

Date

Include a $60.00 Application Fee made payable to the Kansas State Department of Education. Money order or cashier's check preferred. Personal checks accepted. DO NOT SEND CASH. Mail to: Teacher Licensure and Accreditation, KSDE, Landon State Office Building, 900 SW Jackson Street, Suite 106, Topeka, KS 66612-1212 Processing fee CANNOT be refunded and does not guarantee a certificate will be issued.

KSDE is no longer printing and mailing paper licenses

You can view, save or print a copy of your license online at License Look-up at . Enter the requested information and hit "search". When the search is completed, your license information page will display and you will see a button to "Print License". You may save a PDF and/or print a copy of your newly issued license using the Print License button.

You may also track your application processing through License Look-up. As soon as your status goes to "Printed" or "Not Active", the Print License button will become available and will remain available to you throughout the validity of your license. A license or certificate printed from the License Look-up website may be considered an "official copy" for district files.

Form 3b ? Upgrade Exchange TN and EX

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Revised 12-15

II. APPLICATION INFORMATION Please mark the appropriate action:

I wish to upgrade my one year non-renewable license to a full standard license. I wish to upgrade my exchange license to a full standard license. I wish to upgrade my transitional license to a full standard license.

III. BASIS FOR UPGRADE Please note requirements on the attached upgrade information form.

Please mark the appropriate renewal option:

College Credit to meet the GPA or the recency requirement ? complete Section IV.

Accredited Experience to meet the recency requirement ? complete Section V and Verification of Accredited

Experience form.

Completion of appropriate tests: I have attached my official score report with a passing score for the appropriate content test. OR I selected the code for KSDE as a score recipient for my score(s) when I registered for the test. OR

If unable to verify official scores based on one of the above, you will need to log onto the ETS website and select KSDE as a score recipient OR a university may provide you with a verification of you scores if you coded the university as a score recipient.

SECTION B ? SUPPORTING DOCUMENTATION

IV. EDUCATION INFORMATION

A. List all regionally accredited colleges and universities in order of attendance where courses were taken during the exchange certificate/license.

Name of College/University

State

List your Degree - if earned

Last term Semester Hours

Year

of

Earned for this

Earned attendance

renewal

B. Attach official transcripts of credit hours completed.

V. TEACHING EXPERIENCE INFORMATION

A. List all accredited school experience completed during the exchange certificate/license

School

City

State

Dates of Employment

B. Attach completed experience verification form.

Form 3b ? Upgrade Exchange TN and EX

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Revised 12-15

VERIFICATION OF ACCREDITED EXPERIENCE FOR KANSAS LICENSURE SECTION A ? TO BE COMPLETED BY APPLICANT

Social Security Number Legal Name

___ ___ ___ - ___ ___ - ___ ___ ___ ___

(First)

(Middle)

(Last)

Mailing Address

City

State

Zip Code

Birthdate (MM/DD/YYYY) Former Name(s)

Gender

Male Female

Phone: Alternate Phone:

___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___ ___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___

I have no accredited experience in the most recent six (6) year period. I hereby give my former and/or current employer permission to release any and all information required in Section B.

Signature of Applicant

Date

SECTION B ? TO BE COMPLETED BY EMPLOYING SYSTEM

The above named individual was employed in our school system as verified below.

Name of School System

Accreditation Information State Accredited School?

NO YES

If not state accredited, attach verification of accreditation status.

School Street Address

City

State

Zip Code

Beginning Date of Employment Ending Date of Employment

(MM/DD/YYYY)

(MM/DD/YYYY)

Assignment Include teaching, administrative, school specialist assignments

Grade level

Experience was full-time under contract OR

Experience was at least half-time (.5 FTE) but less than full-time OR

Experience was less than half-time under contract

Total number of years employed in the district

Administrator's Name (Please Print or Type)

Administrator's Position

School Phone Number

Administrator's Signature

Date

PLEASE RETURN TO APPLICANT

IN A SEALED OFFICIAL SCHOOL ENVELOPE

THIS FORM MAY BE DUPLICATED FOR ADDITIONAL EMPLOYERS

Form 3b ? Upgrade Exchange TN and EX

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Revised 12-15

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