Verification Of Highly Qualified Status
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1
2V
H
Q
S
ERIFICATION OF
IGHLY
UALIFIED
TATUS
B
S
A
Y A
TATE
GENCY
T
A
: F
. P
.
O THE
PPLICANT
ILL IN THE INFORMATION ABOVE THE BROKEN LINE
LEASE TYPE OR PRINT
last name
first name
middle name
maiden
street address
city
state
zip code
social security number
date of birth (month, day, year)
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T
S
:
E
A
L
O
O THE
TATE
DUCATION
GENCY
ICENSURE
FFICER
Please complete the information below as it applies to the above-named applicant for NC teacher licensure and
return to the individual at the address above.
The applicant is highly qualified for licensure in
based
Subject/area/grade level
on meeting our state’s testing requirement for that subject/area on
.
date
The applicant is highly qualified for licensure in
based
Subject/area/grade level
on meeting the HOUSSE Standard of this state on
.
date
Designated State Licensure Officer (print name)
Signature
Date
State
Email address
Public Schools of North Carolina
Department of Public Instruction
Licensure Section
6365 Mail Service Center
Form OS-HQ
Raleigh, North Carolina 27699-6365
August 2008
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