Form C-2 - Program Completion Report - Oregon Teacher Standards And Practices Commission Page 2
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1
2Program Completion Report (Form C-2)
To applicant: Complete the following section and send this form to the director of teacher education at the college or university where you completed
your professional education program.
Name
(Last)
(First)
(Middle)
(Previous)
Mailing
Address
(Street or Box No.)
(City)
(Zip Code)
SSN:
Phone No. Home (
)
Date of Birth:
Work (
)
I AM APPLYING FOR:
FULL-TIME LICENSURE IN OREGON.
Counselor, Psychologist, or Administrator Program
To director of teacher education: This applicant has applied for an Oregon counselor, psychologist, or administrator license. Please complete
sections below in ink.
School Counselor Program
School Psychologist Program
1)
Has the above-named educator completed all requirements
1) Has the above-named educator completed all requirements
for full licensure with no restrictions
Yes
No
for full licensure with no restrictions
Yes
No
(If no, explain)
(If no, explain)
2) Date of Completion______________________________________
2) Date of Completion________________________
3) AT WHAT GRADE LEVELS:__________________________
3) AT WHAT GRADE LEVELS:________________
Administrator Program
1)
Has the above-named educator completed all requirements for full licensure with no restrictions
Yes
No (If no, please explain)
2)
Date of Completion____________________________________
3)
AT WHAT GRADE LEVELS:___________________________
Verification from Director of Teacher Education:
I verify that the applicant has completed the professional education program successfully and in good standing.
Director of Teacher Education (Signature)
Date
(
)
College or University
City & State
Phone Number
THIS FORM MUST BE RETURNED TO THE APPLICANT IN A SEALED INSTITUTIONAL ENVELOPE
.
For Office use:
(TSPC.0002 – 03/16/2009)
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