Institutional endorsement and assurances-teacher




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Wisconsin Department of Public Instruction

INSTITUTIONAL ENDORSEMENT AND ASSURANCES—TEACHER

PI-1612-T (Rev. 02-15)

Forms are available at: http://tepdl.dpi.wi.gov/licensing/supplementary-forms


INSTRUCTIONS TO INSTITUTION: Complete Section II and return to applicant:

Website: http://tepdl.dpi.wi.gov/

Educator Licensing Telephone:
(608) 266-1027 or (800) 266-1027

I. APPLICANT INFORMATION Completed by Applicant

Legal Name First

     


Middle Int.

  


Last

     


Email Address

     


Home Address Street, Box, City, State, Zip

     


Telephone Area/No.

     


Name and Location of Institution

     


Degree Earned

     


Date of Graduation Mo./Year

     


License(s) Requested

     


II. INSTITUTIONAL ENDORSEMENT AND ASSURANCES Completed by Educator Preparation Program and Returned to Applicant

1. Did the applicant complete your institution’s state-approved program leading to an educator license?

 YES,


Applicant completed program on:

     

(Mo./Yr.)

Identify below educator license(s) for which applicant qualifies in your state.





License Area

Subject/Category and/or Position

Grade/Development Level

 Teacher


     

     

      


     

     

 NO, Explain:


     

2. The license(s) recommended in question 1 (above) is based on completion of a:



 Major in:

     

 Minor in:

     


3. Supervised Field Experiences (complete a and b, or c):

a. Applicant completed a pre-student teaching practicum(s) in:



     

(Subjects/Grades)

b. Applicant completed student teaching in

     

(Subjects/Grades)

for

   

Weeks

in an:

 Elementary School

 Middle School

 High School

 Other Setting

c. Applicant completed a graduate practicum?

 Yes, Position and Level:

     

 No

4. Testing—Did the applicant meet your state’s passing scores on a:

a. Basic skills test in reading (R), writing (W), and math (M)?

 Yes,

Test Name(s) and Year:

     

No

 Test Not Required

b. Standardized content test in all areas of licensure listed in question 1 above?

 Yes,

If ETS/Praxis II or ACTFL Content test(s), list Test Number, Score, and Year below.

No

 Test Not Required




Test Number

     


Score

     


Year

    





I, THE CERTIFYING OFFICER, CONFIRM that the education and testing information provided above is accurate and that the applicant is eligible for licensure in our state on the basis of having completed our state-approved program:

Signature of Certifying Officer



Name Type or Print Legibly

     


Date Signed Mo./Day/Yr

     


Institution Name

     


City/State

     


Telephone Area/No.

     


E-Mail Address

     


Fax Area/No.

     





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