Teaching License Application

Please complete ALL fields.

First Name

Middle Name

Last Name

Maiden Name/other last name aliases

Date of Birth (e.g. 2/13/91)

T-Number

Gender

Male

Female

Street/P.O. Box

City

State

Zip

Telephone Number - include area code

E-mail address

Cell Phone Number/Alternate Phone Number

Which of the following are you applying for -check all that apply.

Practioner license - Educational

Adding an endorsement

Adding a degree

ILLA/ILLB

Practioner license - Occupational

Practioner license - School Counseling

Practioner license - School Psychology

INFORMATION NEEDED FOR FEDERAL REPORTING - COMPLETE BOTH ETHNICITY & RACE

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Race

PLEASE READ CAREFULLY BEFORE SUBMITTING - MUST BE COMPLETED

Personal Affirmation: Failure to complete this section will result in your application being returned without processing. False statements made in this application may constitute grounds to take action, revoke or deny a license. Check the appropriate block for each question. DO NOT include matters that the State Board of Education has already investigated and found "No Probable Cause" to take any disciplinary action.

1. Have you been convicted of a felony, including conviction on a plea of guilty, a plea of nolo contend ere or order granting pre-trial diversion?

Yes

2. Have you been convicted of the illegal possession of drugs, including conviction on a plea of guilty, a plea of nolo contend ere or order granting pre-trial diversion?

Yes

3. Have you had a teacher's certificate/license revoked, suspended or denied, or have you voluntarily relinquished a certificate/license? (Allowing a license to expire does not count.)

Yes

4. Is there any action pending against your certificate/license or application in another state?

Yes

Please list the edorsement area(s) being requested for this application:

* Please enter atleast one endorsement.

Are your passing test scores showing in TN Compass?

Yes

If no, list the testing date. (e.g. 2/13/14)

By signing this form, I agree that the above information is correct to the best of my knowledge and give TTU's College of Education permission to submit my application for a State of Tennessee Educator License.