Form Ed2331 - Application For Transitional License printable pdf download

Tennessee Department of Education – Office of Educator Licensing

710 James Robertson Parkway - Andrew Johnson Tower, 12

Floor - Nashville, TN 37243

This form must accompany any request for licensure transactions in the State of Tennessee. Please complete using black ink. Required items are identified with an

asterisk (*). The personal affirmation section must be completed.

SECTION 1. CONTACT AND DEMOGRAPHIC INFORMATION

This section must be completed. Please be certain to provide accurate information.

First Name*

Middle Name*

Last Name*

(Maiden/Other Last Name)

Date of Birth*

Street/P.O. Box*

City*

State*

Zip Code*

(MM/DD/YYYY)

Primary Telephone Number*

Secondary Telephone Number

Social Security Number*

(999) 999-9999

999-99-9999

Primary Email Address*

Secondary Email Address

The following information is collected for the purposes of federal reporting requirements. Please provide responses for ethnicity, race and gender.

Ethnicity – Choose one

Hispanic or Latino

Not Hispanic or Latino

Race – Mark all that apply

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian/Other Pacific Islander

White

Gender

Male

Female

SECTION 2. PERSONAL AFFIRMATION*

This section must be completed. False statements made in this application may constitute grounds to take action, revoke or deny a license. Check the appropriate

response for each question. Do not include matters that the State Board of Education has previously investigated and found “No Probable Cause” to take any

disciplinary action.

Yes

Have you been convicted of a felony, including conviction on a plea of guilty, a plea of nolo

contendere or granting pre-trial diversion?

Yes

Have you ever been convicted of the illegal possession of drugs, including conviction on a please of

guilty, a plea of nolo contendere or an order granting pre-trial diversion?

Yes

Have you had a teacher’s certificate/license revoked, suspended or denied, or have you voluntarily

relinquished a certificate/license. (Allowing a license to expire does not apply.)

Yes

Is there any action pending against your certification/license or application in another state?



If you have answered “Yes” to question 1 or 2, please attach details of conviction, include date and location of conviction, and court certified copies of the

judgment, conviction, and sentencing.



If you have answered “Yes” to question 3 or 4, please attach details naming the state and/or issuing authority and explain the circumstances.

SECTION 3. SIGNATURE AND DATE*

This section must be completed.

Applicant Signature

Date

SECTION 4. LICENSURE TRANSACTION REQUESTED

Please indicate the type(s) of licensure transaction(s) being requested. Mark all that apply.

Initial License (submitted by EPP through TNCompass)

Address Change

National Board Certification (Attach supporting documents)