Application To Extend A Teaching Intern Certificate Form printable pdf download

PPLICATION TO

EXTEND

EACHING

NTERN

ERTIFICATE

– C

RIZONA

EPARTMENT OF

DUCATION

ERTIFICATION

NIT

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

Alternative Pathways to Teacher Certification Telephone: (602) 542-5344

HE TEACHING INTERN CERTIFICATE IS VALID FOR ONE YEAR AND MAY BE EXTENDED YEARLY FOR NO MORE THAN TWO

. T

CONSECUTIVE YEARS

HE TEACHING INTERN CERTIFICATE ENTITLES THE HOLDER TO ENTER INTO A TEACHING CONTRACT

. D

WHILE COMPLETING THE REQUIREMENTS FOR AN

RIZONA PROVISIONAL TEACHING CERTIFICATE

URING THE VALID PERIOD

(

)

OF THE TEACHING INTERN CERTIFICATE THE HOLDER MAY TEACH IN A STRUCTURED

NGLISH IMMERSION

SEI

CLASSROOM OR

(

). T

IN ANY SUBJECT AREA IN WHICH THE HOLDER HAS PASSED THE APPROPRIATE

RIZONA EDUCATOR EXAM

NES OR AEPA

CANDIDATE SHALL BE ENROLLED IN AN

RIZONA STATE BOARD AUTHORIZED ALTERNATIVE PATH TO CERTIFICATION PROGRAM

. A

OR AN

RIZONA STATE BOARD APPROVED TEACHER PREPARATION PROGRAM

N INDIVIDUAL IS NOT ELIGIBLE TO HOLD THE

CERTIFICATE MORE THAN ONCE IN A FIVE

YEAR PERIOD

GENERAL INSTRUCTIONS AND INFORMATION:

Please submit the following:

A. A completed Application to Extend a Teaching Intern Certificate. There is NO FEE to extend the Teaching Intern

certificate.

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

C. A letter from the Board approved alternative path to certification program or an Arizona State Board authorized

teacher preparation program verifying the completion of required coursework.

(Must be signed by an approved

designee. See list of approved institutions for contact information:

certification/files/2013/10/information-ihealternativepathflyer.pdf?20140909

D. Official transcripts documenting the required coursework must accompany the letter.

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

Social Security Number:

________-_______-___________

Date of Birth:

_____/_____/________

Gender:

M / F

(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: CERTIFICATION TYPE

TEACHING CERTIFICATES:

___ Elementary Education, 1-8

___ Arts Education, PreK-12

................................................

Additional Approved Area(s):

________________________

Select One:

Art

Dance

Dramatic Arts

Music

___ Secondary Education, 6-12

___ Early Childhood Education, Birth to Age 8 or

Select Primary Approved Area:

________________________

Grade 3…………………………………………………….

Additional Approved Area(s):

________________________

SPECIAL EDUCATION CERTIFICATES:

___ Cross-Categorical, K-12 (ED, LD, ID, O/OHI)

___ Intellectual Disability, K-12

___ Early Childhood, Birth to Age 5

___ Orthopedic/Other Health Impairments, K-12

___ Emotional Disability, K-12

___ Severely and Profoundly Disabled, K-12

___ Hearing Impaired, K-12

___ Visually Impaired, K-12

___ Learning Disability, K-12

** R

. **

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

RIZONA

EVISED

TATUTES AND

DMINISTRATIVE

ODE

Revised 6-25-2015

-C

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ERTIFICATION

Application To Extend A Teaching Intern Certificate Form

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