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:
INSTRUCTIONS TO INSTITUTION: Complete Section II and return to applicant:
Educator Licensing Telephone:
(608) 266-1027 or (800) 266-1027
I. APPLICANT INFORMATION Completed by Applicant
Legal Name First
Home Address Street, Box, City, State, Zip
Name and Location of Institution
Date of Graduation Mo./Year
II. INSTITUTIONAL ENDORSEMENT AND ASSURANCES Completed by Educator Returned to Applicant
Preparation Program and
1. Did the applicant complete your institution’s state-approved program leading to an educator license?
Applicant completed program on:
(Mo./Yr.) Identify below educator l icense(s) for which applicant qualifies in your state.
Subject/Category and/or Position
NO , Explain:
2. The license(s) recommended in question 1 (above) is based on completion of a:
Major in: Minor in:
3. (complete a and b, or c):
Supervised Field Experiences
a. Applicant completed a pre-student teaching practicum(s) in:
b. Applicant completed student teaching in
c. Applicant completed a graduate practicum?
Yes, Position and Level:
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)?
Test Name(s) and Year:
Test Not Required
b. Standardized content test in all areas of licensure listed in question 1 above?
If ETS/Praxis II or ACTFL Content test(s), list Test Number, Score, and Year below.
Test Not Required
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