PI-2450 Public Librarian Certification Application by lsNgb9V


									               Wisconsin Department of Public Instruction                                      INSTRUCTIONS: Complete this form, enclose the necessary
               PUBLIC LIBRARIAN CERTIFICATION APPLICATION                                      attachments, and submit to:
               PI-2450 (Rev. 04-12)                                                                WISCONSIN DEPARTMENT OF PUBLIC INSTRUCTION
                                                                                                   ATTN: DEBRA ANKLAM
               Required by s. 43.09(1) Wis. Stats. and PI 6.03(2) Wis. Admin. Code.
                                                                                                   P.O. BOX 7841
               For information about certification, see the Certification Manual for               MADISON, WI 53707-7841
               Wisconsin Public Library Directors (dpi.wi.gov/pld/cert.html)

                                                                          I. GENERAL
Last Name                                             First Name                       Middle Name                       Other Last Name(s) Previously Used

Mailing Address Choose one        Alternate Mailing Address
   Use public library address     Street / PO Box                                           City                                   State     ZIP
    Use alternate address
Email Address                                                                                                            Phone Area/No.

Current Position                  Date Hired                   Library Where Currently Employed
                                  If New Director
    Other Specify
                                                               Public Library System

                                                        II. TYPE OF CERTIFICATION REQUESTED
Grade Level Requested             Type of Certification Choose one                                                       Expiration Date of Current Certification
Choose one                                                                                                               Renewal or Provisional, Mo./Yr.
                                      First Regular              Renewal of Regular                Provisional
    I          II        III
                                      First Temporary            Renewal of Temporary

                                                                     III. ENCLOSURES
                                              Official documentation must be submitted for all first certification.
                         First Regular Certification                                                      First Temporary Certification
General Education Requirements            Library Course Requirements               General Education Requirements            Library Course Requirements
                                          Except for applicants with master’s
Official documentation Choose one                                                   Official documentation Choose one             Official documentation of
                                          degree in library science
    Master’s (or higher degree) in                                                        Bachelor’s (or higher degree)           required library courses
                                               Official documentation of                                                          already completed
    library science
                                               required library courses                   Bachelor’s degree with a minor
                                                                                                                                  Schedule for completion of
    Bachelor’s degree with a minor in                                                     in library science
                                                                                                                                  certification course
    library science *
                                                                                          At least 54 semester credits            requirements Required
    Bachelor’s degree **
    At least 54 semester credits **
          * Requires Advanced Public Library Administration
          ** Requires coursework in four designated subject areas
Renewal of Regular Certification                  Renewal of Temporary Certification                 Certification Fee Nonrefundable fee to defray handling
                                                                                                     costs. Make check payable to DPI. Choose one
    Validated Annual Summations of                    Official documentation of library
    Continuing Education Activities                   courses completed since last                       $50 Regular or Provisional Certification
    (Form PI-2454)                                    certification
                                                                                                        $10 Temporary or Lapsed Certification

                                                                       IV. SIGNATURE
I CERTIFY that the above information is true and correct to the best of my knowledge. I understand that any false statements may result in denial or
revocation of the certificate.
Applicant Signature                                                                                                                Date Signed Mo./Day/Yr.

                                                                       V. FOR DPI USE
DLT Recommendation for Approval                                            Signature of DLT Certification Coordinator             Date Signed Mo./Day/Yr.
   Grade 1    Regular       Certification           To Expire on the
    Grade 2         Temporary         First
                                                    Last Day of Mo./Yr.
    Grade 3         Provisional       Renewal

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