Form 26859 - Application For Public Library Certificate

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APPLICATION FOR PUBLIC
CERTIFICATION PROGRAM COORDINATOR
LIBRARY CERTIFICATE
Professional Development Office, Indiana State Library
State Form 26859 (R4 / 5-08)
140 North Senate Avenue, Indianapolis, IN 46204-2296
Approved by State Board of Accounts, 2008
317-234-5650 or 1-800-451-6028 (Indiana only)
Fax: 317-232-3713
INSTRUCTIONS:
WWW: E-mail: pdo@library.in.gov
1. Fill out the application form completely. Only supply one address (work or home).
2. Send a certified copy of your transcript along with the application.
3. Send a check or money order for $50 payable to the Indiana State Library.
4. Mail the application to the Professional Development Office, address is listed at the above right.
NOTE: Information provided is a public record
Date (month, day, year )
Personal/Work E-mail:
Last Name
First Name
Middle Name
Home Address (number and street, city, state and ZIP code )
Maiden Name (if applicable )
Telephone (include area code )
Library Name
Work Address (number and street, city, state and ZIP code )
Please check the type and level of certification in which you are applying in the space below .
Type
Level
Librarian
1
4
Specialist
2
5
Temporary
3
6
Please list the highest degree obtained
GENERAL EDUCATION (NOT Library Training. This goes under NEXT heading.)
Dates of Attendance
Dates of Graduation
Degree
School Attended
LIBRARY EDUCATION
Dates of Attendance
College Credits Received
Degree/Diploma and Date
NAME OF INSTITUTION AND STATE
1. ALA-Accredited Library School
(i.e.,degree obtained )
2. Approved Library Science Education
(590 IAC 5-1-6)
(If more space is needed, use an additional sheet repeating headings.Dates should include beginning and ending day, month, and year.)
PROFESSIONAL LIBRARY EMPLOYMENT
Position Held
Dates
Principal Duty
NAME OF LIBRARY AND STATE
Present Position
Previous Position
Previous Position
INSTRUCTIONS: Applicant must be sure to supply all signatures called for below.
The information given in the application is correct, and on the basis of it, I, the applicant, apply for,
Certificate as (Class or Grade )
Temporary Permit as (Class or Grade )
I enclose $50.00
in
Personal check
Money Order
Applicant's Signature

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