Application For Wyoming Certification Of Teachers, Administrators, And Other Personnel Page 2

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APPLICATION FOR WYOMING CERTIFICATION OF TEACHERS,
ADMINISTRATORS, AND OTHER PERSONNEL
Section A. Please print or type
1.
Social Security Number: _________-_________-____________
2.
Name:________________________________________________________________________________
Last
First
Middle
Maiden/Former
3.
Mailing address:________________________________________________________________________
PO Box/Street
City
State
Zip
4.
Telephone:
(_______)_______-__________
(_______)______-________
Work
Home
5.
Birth date:___________________
Male_____
Female_____
6.
Ethnicity: Asian_____
Black_____
Hispanic_____
Indian/Alaskan_____
White_____
7.
Have you held a Teaching or Administrative Certificate or Permit?
Yes___
No___
If other than Wyoming, please submit a copy if it is still valid.
Under what Name(s)_____________________________________________________________________
State(s)_______________________________________________________________________________
8.
Endorsement(s) you are requesting:_________________________________________________________
9.
Do you currently have a teaching position in Wyoming? Yes__ No__ If yes, complete the following:
_____________
______________________________________________________________________
School District Name and Number
School
Level
Subject
10.
I,_________________________________________________, affirm under penalty of perjury under the
laws of the State of Wyoming that all information included in this application is true and correct.
Signature:_________________________________________________________ Date_______________
PTSB, 307-777-7291
2300 Capitol Avenue
Cheyenne, WY 82002
4/00
6

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