Application To Extend Provisional Teaching, Secondary Stem, Or Administrative Certificate With Structured English Immersion (Sei) Endorsement Deficiency Form printable pdf download

, S

STEM,

PPLICATION TO

XTEND

ROVISIONAL

EACHING

ECONDARY

(SEI)

DMINISTRATIVE

ERTIFICATE WITH

TRUCTURED

NGLISH

MMERSION

NDORSEMENT

EFICIENCY

– C

RIZONA

EPARTMENT OF

DUCATION

ERTIFICATION

NIT

Mailing Address: P.O. Box 6490, Phoenix, AZ 85005-6490 • Telephone: (602) 542-4367

GENERAL INSTRUCTIONS AND INFORMATION

On September 28, 2015, the State Board of Education approved a Certification rule change which allows individuals who hold a teaching or administrative

certificate with an SEI deficiency to meet the SEI endorsement requirement in three years instead of one year. This form may be used to apply to extend a

Provisional Teaching, Provisional Career and Technical Education, Administrative, or Secondary STEM certificate with an SEI deficiency to three

years from date of issue per the State Board rule change.

Submit the following:

Checklist:

□

Completed Application.

o Answer EVERY Criminal History Question, sign and date the application.

o If you answer “Yes” to any Criminal History questions, you MUST submit a completed

Explanation of

Incident

form.

□

A photocopy of your valid Arizona Department of Public Safety Identity Verified Prints (IVP) fingerprint card.

□

If you are applying to remove the Arizona and/or United States constitution deficiency, submit official transcript(s) or a

photocopy of the passing AZ and US Constitutions exam score report. Note: If you are certified in History, Political

Science/American Government, or Middle Grade Social Studies and have an Arizona and/or US constitution deficiency

you must remove this deficiency in order to extend your one-year certificate.

□

A check or money order for the appropriate fee. The fees are: $20 per certificate to be extended; $20 if you are

removing the AZ and/or US Constitution deficiency. Certification fees will not be refunded even if you do not

qualify for the requested service.

Are you removing an AZ and/or US Constitution deficiency? __YES __NO

I have am removing the deficiencies:

__ US Constitution Deficiency __ AZ Constitution Deficiency ……$20

SECTION 1: PERSONAL INFORMATION (TYPE OR PRINT IN BLUE OR BLACK INK)

________-_______-___________

_____/_____/________

M / F

Social Security Number:

Date of Birth:

Gender:

(For identification purposes only)

Full Legal Name:

________________________________________________________________________________________________

Last

First

Middle

Mailing Address:

________________________________________________________________________________________________

Street Number or P.O. Box

City

State

Zip

(______) ______-________

_________________________________________

Telephone:

Email Address:

Ethnicity:

____American Indian or Alaskan Native

____Black or African-American (Not-Hispanic)

____White (Not-Hispanic)

____Asian or Pacific Islander

____Hispanic or Latino

____Other

(Gender and Ethnicity are requested for federal reporting purposes only)

SECTION 2: CERTIFICATE(S) TO EXTEND

I am requesting a temporary extension of the following certificate(s) due to the State Board rule change. I understand that if I am granted

an extension I must satisfy the SEI endorsement requirement and ALL other deficiency requirements by the expiration date of my extended

certificate in order to maintain my qualification to teach in Arizona public schools.

___Provisional Elementary ($20)

___Provisional Special Education ($20 each)

___Provisional Arts Education ($20)

___Provisional Early Childhood ($20)

___Provisional Secondary ($20)

___ Provisional CTE ($20 each)

___Provisional PreK-12 Physical Education ($20)

___ Secondary STEM ($20)

___ Principal ($20)

___ Superintendent ($20)

___ Supervisor ($20)

** R

. **

EQUIREMENTS MAY BE SUBJECT TO CHANGE AND ARE FULLY REFERENCED IN THE

RIZONA

EVISED

TATUTES AND

DMINISTRATIVE

ODE

Version 1 (Rev. 9-28-2015)

-C

Page 1 of 2

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DUCATOR

ERTIFICATION

Application To Extend Provisional Teaching, Secondary Stem, Or Administrative Certificate With Structured English Immersion (Sei) Endorsement Deficiency Form

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