Renewal Application For Wyoming Certification Of Teachers, Administrators, And Other Personnel Form
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1(Fee payable to:)
(1/99)
Professional Teaching Standards Board
Telephone: (307) 777-7291
nd
Hathaway Building, 2
Floor
In-State: (800) 675-6893
2300 Capitol Avenue
Fax: (307) 777-6234
Cheyenne, WY 82002
E-mail:
lstowe@missc.state.wy.us
Renewal Application for Wyoming Certification of Teachers,
Administrators, and Other Personnel
PLEASE READ CAREFULLY **Renewal (non-refundable) fee: $90.00** Personal checks are accepted. This Renewal
Application must be received in this office no later than the expiration date posted on your certificate.
If you are working in a Wyoming school district, the renewal certificate will be sent directly to your local superintendent's office
unless otherwise requested.
1. PLEASE COMPLETE:
a) Have you ever been convicted of a felony or misdemeanor (other than a misdemeanor
Yes
No
traffic offense or traffic infraction)? If yes, please submit a notarized statement detailing
the incident and disposition.
b) Have you ever had a teacher, administrator, special services license, certificate or any other
Yes
No
occupational permit, license, credential, or equivalent document subjected to any disciplinary
proceeding, including but not limited to, denial, reprimand/admonition credential, suspension
or revocation, or have you ever voluntarily surrendered such a document in Wyoming or any
other state or place, or are you currently under investigation? If yes, please state on a separate
sheet of paper the allegation, disciplinary action and the final disposition.
c) Have you ever been dismissed or discharged, or have you resigned in order to avoid discipline
Yes
No
or discharge by any employer? If yes, please state on a separate sheet of paper, the name,
address, and telephone number of employer, the nature of the allegations and the final disposition.
2. Social Security Number
Phone: Home (
)
Work (
)
Full Legal Name
Last
First
Middle
Former Name
Mailing Address
P.O. Box/Street
City
State
Zip Code
3. CREDITS: you are responsible to request official transcripts verifying completion of renewal requirements. Please list
transcripts requested and/or attached.
College/University
State
Date Requested
4. New endorsements you are requesting (Institutional Recommendation (IR) form must be requested from this office, and you
must send it to your college):
5. Experience: Please list all teaching, administrative, and other personnel experience (grades K-12) since last renewal:
Year
School
State
Grade Level
Subject Area
6. Do you currently have a teaching position in Wyoming?
Yes
No
If yes, complete the following:
School District Name & Number
School
Grade Level
Subject Area
7. Date
Applicant Signature
**Upon receipt of application in this office, other materials to finalize process must be received with 90 days or fee will be forfeited
and an additional fee will be requested.**
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