Application For Educator'S License - Arkansas Department Of Education
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APPLICATION FOR EDUCATOR’S LICENSE
MAIL TO:
Telephone No: (501) 682-4342
Arkansas
EDUCATOR LICENSURE
Fax No: (501) 682-4898
DEPARTMENT OF EDUCATION
Web Page:
ROOMS 106B & 107B
NOTICE
FOUR CAPITOL MALL
Incomplete applications will be returned
LITTLE ROCK, AR 72201-1071
without action, with omissions checked.
DEPARTMENT OF EDUCATION
Educator Licensure
F
A
CR
PLEASE PRINT IN INK OR TYPE
Central Registry Check:
All coursework must be documented by providing
Applicable Fees
:
Being Forwarded To DHS
On File
original college transcripts:
Non Criminal Background Check
:
Being Forwarded
Being
On
On File
Enclosed
Enclosed
Pay Online
To AR. State Police
Forwarded
File
Date: __________________
Date of Birth: ______/_______/_______
SSN: _______ - _______ - ________
Name:
First
Middle
Last
Maiden
Mail License To:
Home Phone: _____________________________
Cellular Phone: _____________________________
Name
Work Phone:
_____________________________
Fax:
_____________________________
Street and/or Route Number
Apartment #
Email:_____________________________________
Years of Licensed Teaching Experience___________
City
State
Zip
Have you ever held an Arkansas teaching license?
PROCESSING FEE
FOR STATISTICAL PURPOSES
CHECK ONE
Yes
No
(IF APPLICABLE)
ONLY:
Have you ever had a license revoked in any state?
Gender:
Male
Female
Yes
No
Have you ever had a “true finding” with the Arkansas
( ) $75 - 5 YEAR STANDARD
Ethnicity: Check One
Department of Human Services Child Maltreatment Central
( ) $75 - 5 YEAR RENEWAL
Registry?
( ) Hispanic / Latino
( ) Non- Hispanic/ Latino
Yes
No
( ) $50 - DUPLICATE
If yes, what was the finding?
_____________
Race: Check one or more
( ) $75 - 5 YEAR
Have you ever pled guilty or pled nolo contendere (no
TECHNICAL PERMIT
( ) American Indian Or
contest) or been found guilty of a crime?
Alaskan Native
Yes
No
PLEASE NOTE:
( ) Asian or Pacific
NO PERSONAL CHECKS
If yes, was the crime a
Islander
:
Felony or
Misdemeanor
ACCEPTED
( ) Black or African
Educators can pay on-line by credit
What was the date and crime for which you were
American
card or electronic check at
convicted? _____________________________
( ) White
https://
licensure
Money orders or cashier
.
Is your license currently under disciplinary review in
( ) Native Hawaiian or
checks may also be accepted.
another state or country?
Other Pacific Islander
Yes
No
( ) Other
If licensed outside the state of Arkansas, has your license
been in good standing for the previous two years?
U.S. Citizen
Yes
No
Yes
No
Please be aware that the Arkansas Department of Education has access to and must consider any background check reflecting a
conviction (pleading guilty or nolo contendere (no contest) or being found guilty by a jury or judge) for any offense listed in Ark.
Code Ann. § 6-17-410 as well as any felony involving physical or sexual injury, mistreatment, or abuse against another, including
records that have been expunged, sealed or subject to a pardon. For any questions about this, please call the ADE legal office @
(501) 682-4227.
Please indicate the application type.
Provisional
Non-Traditional (APPEL)
Converting Initial to Standard
Duplicate
Standard
Non-Traditional MAT/ MED/MTLL Converting Provisional to Standard
Name Change
Renewal
Teach for America
Career &Technical Permit
Correction
Lifetime License
Teacher Corps
Adding Degree
Change of Address Only
Reciprocity
Professional Teaching Permit
Adding Area
Reciprocity- ( out of Provisional Professional Teaching License
Country)
Please indicate the degree level of your license.
Less than Bachelor’s
Bachelor’s
Master’s
Specialist
Doctorate
To be completed by applicant only when adding an additional licensure area by testing.
Licensure Area(s)
Grade Level
Signature of Applicant:
__________________________________________________________________________________
09/02/2015
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