1.
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Date of Application
2.
*

Social Security Number
3.
*

Certification Sought
4.
*

Grade Level
5.
*

Last Name
6.
*

First Name
7.

Middle Initial
8.
*

Current Address (Street/Box #, Apt.#, City,  State, Zip)
9.
*

Telephone Numbers (home, work, mobile)
10.
*

E-Mail Address (home or work)
11.
*

Are you a United States Citizen?
Yes   No
12.
*

Are you a veteran of the United States Armed Services?
Yes   No

Education
13.
*

Provide the following information regarding your education (school of attendance, address, dates of attendance, major, degree received)

Teaching Experience
14.

Provide the following information regarding your teaching experience (school, address, dates of attendance, administrator name, position held, reason for leaving)
15.
*

Are you currently certified to teach in the state of Wisconsin?
Yes   No
16.

If yes, in what areas
17.
*

Do you currently have an emergency permit to teach?
Yes   No
18.

If yes, issuing agency
19.
*

Have you ever been granted any type of teaching permit in the state of Wisconsin?
Yes   No
20.
*

Are you currently teaching in a K-12 classroom?
Yes   No
21.

If yes, please provide the following - disrtrict, school, grade level, subject area

PRAXS I and II
22.
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Have you taken the PRAXIS I test (PPST)?
Yes   No
23.

If yes, please list your score for Math (please send a hard copy of your score to CESA 6, Attn: Donna Runice)
24.

If yes, please list your score for Reading (please send a hard copy of your score to CESA 6, Attn: Donna Runice)
25.

If yes, please list your score for Writing (please send a hard copy of your score to CESA 6, Attn: Donna Runice)
26.
*

If no, have you scheduled an exam date?
Yes   No
n/a
27.
*

Have you taken the PRAXIS II test?
Yes   No
28.

If yes, please list your score here (please send a hard copy of your score to CESA 6, Attn: Donna Runice)
29.
*

If no, have you scheduled an exam date?
Yes   No
n/a

Volunteer History (activities working with children)
30.

Please provide the following information regarding your volunteer history - name or organization, address, dates of volunteer, position held, nature of activity

Experiences with Children
31.
*

Briefly describe your experiences with children and state your primary reason for wanting to become a teacher.

I submit this form with the understanding that I will be required to meet local district employment requirements, and meet all admission requirements of the program. I also understand that if admitted, I would commit to:

• Successfully passing the PRAXIS I: PPST
• Successfully passing the PRAXIS II content assessment test in my intended teaching field
• Applying for any necessary emergency permits
• Satisfying any and all financial obligations of the program
• Completing all program requirements







I fully understand that participation in the program is contingent upon my status as Teacher of Record in my classroom, and that if for any reason I fail to maintain such status, I will not be able to continue in the program.

I certify the information provided in this application is true and complete to the best of my knowledge. Falsification of information on this application could jeopardize admission and enrollment. I authorize any schools or colleges I have previously attended to release personal and academic information to CESA 6.

All qualified applicants receive consideration for employment without regard to race, color, religion, gender, sexual orientation, age, national origin or ancestry, disability or veteran status through CESA 6. 

Registration Fee
32.
*

Registration fee will be paid by: (Please check one)
Credit Card   Check
33.

If registration fee is to be paid by credit card, please provide the credit card number, expiration date and the 3-digit security code on the back of the card in the box below. (Note: We accept Discover, Mastercard and Visa)

If registration fee to be paid by check, send your payment of $35.00 to the CESA 6 Office, Attn: Donna Runice.
 

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