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Licensure Checklist

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					                                                                             Form #OEL 02-04


                               Licensure Instructions
                               Mississippi Department of Education
                                  Office of Educator Licensure
                                           P.O. Box 771
                                     Jackson, MS 39205-0771
                                           601-359-3483



Please read directions carefully:
      1. Complete and return the Licensure Checklist (Form #OEL 02-04, Sec. A, pages 1-3) and Licensure
      Application (Form #OEL 02-04, Sec. B) with all other required documents as a single, complete
      packet to address above. Incomplete packets will be returned to the applicant with no action
      taken. A complete packet includes Checklist and Application, plus all documents listed in the
      Checklist under your licensure category.

      2. All transcripts from all institutions must be submitted in a sealed envelope(s) bearing the seal
      or signature of the registrar. Do not ask the institution to mail your transcript to this office.
      It should be mailed to you and may be stamped “student issued.” Do not open the sealed
      envelope!

      3. Test scores must be submitted as originals. (Unofficial copies will not be accepted.) Even
      though you have asked the testing company to send your scores to this office, please include
      your original score report with your packet. Your scores will be returned to you.


Additional Information:
Mississippi Department of Education Webpage: http://www.mde.k12.ms.us

      From this page you can access Guidelines for Mississippi Educator Licensure K-12 which
      contains information on:
       License Renewal
       “Highly Qualified” Criteria
       Courses considered for supplemental endorsement
       Alternate Route Programs
       Driving directions to Office of Educator Licensure
       Praxis Tests
       Addresses and numbers for Mississippi colleges and universities

The Office of Educator Licensure Call Center: 601-359-3483
                                                                               Form #OEL 02-04, Sec. A, page 1


                                      LICENSURE CHECKLIST


Applicant’s Name_____________________________________ Date_____________________
All licensure requests may be completed with this Licensure Checklist. Find and check the category that applies to you.
Then, mark the boxes under your category to indicate the documents you have enclosed with your application.


                                                  CATEGORIES

    TRADITIONAL TEACHER EDUCATION ROUTES/APPROVED PROGRAM ROUTES

___Five-Year Teacher Education Route - Initial License (Applies to a graduate of a teacher education
program which included student teaching.)
 Licensure Application (Form #OEL 02-04, Sec.B)
 Transcript(s) (Sealed)
 Test Scores (Original)


___Approved Program Route (Applies to a licensed teacher who wishes to upgrade the license with an
advanced degree. This includes masters, specialist, and doctorate degrees.)
 Licensure Application (Form #OEL 02-04, Sec.B)
 Transcript of the advanced degree (Sealed)
 Institutional Verification of Program (Form #OEL 02-04, Sec.C – Required for Administrator Licenses.)


___Specific Five-Year Educator License (Applies to Guidance and Counseling, Audiologist, Emotional
Disability, Psychometrist, School Psychologist, Speech Pathologist*, Performing Arts**, and Child
Development***)
 Licensure Application (Form #OEL 02-04, Sec.B)
 Transcript(s) (Sealed)
 Test Scores (Original)
 *Original ASHA Membership Card (ASHA Certified Speech Pathologists may omit submission of test scores.)
 **Validation of artistic competency (Required only for applicants for the Performing Arts License with a
   degree in a non-Fine Arts area.)
 ***Verification of Accreditation/Child Development (Form #OEL 02-04,Sec. E)


                                                   RECIPROCITY

___Five-Year Reciprocity License (Applies to applicants with a valid, clear and renewable out-of-state license
and 2 years of out-of-state teaching experience.)
 Licensure Application (Form #OEL 02-04, Sec.B)
 Transcript(s) (Sealed)
 Original, valid, out-of-state teaching license (Photocopies are not accepted.)
 Verification of Out-of-State Teaching/Administrative Experience (Form #OEL 02-04, Sec.G)
 Verification of Highly Qualified Status (Form #OEL 02-04, Sec.D)

                                                                            Form #OEL 02-04, Sec. A, page 2
___Two-Year Reciprocity License (Applies to applicants with a valid credential less than a standard license
from another state, or who possess a valid standard license (K-12) from another state but have less than two
years out-of-state teaching or educational administration/leadership experience.)
  Licensure Application (Form #OEL 02-04, Sec.B)
  Transcript(s) (Sealed)
  Original, valid, out-of-state teaching license (Photocopies are not accepted.)
  Verification of Highly Qualified Status (Form #OEL 02-04, Sec.D)


                                          ALTERNATE ROUTES

___One-Year Alternate Route License (Applies to graduates of a non-teacher education program who have met
the initial requirements of one of the following programs:
                      Mississippi Alternate Path to Quality Teachers (MAPQT) OR
                      Teach Mississippi Institute (TMI)
 Licensure Application (Form #OEL 02-04, Sec.B)
 Transcript(s) (Sealed)
 Test Scores (Original)
 Certificate of Completion from college/university
 Verification of Employment (MAPQT Program only)


___Three-Year Alternate Route License (Applies to graduates of a non-teacher education program who have
met the initial requirements of the Master of Arts in Teaching Program.)
 Licensure Application (Form #OEL 02-04, Sec.B)
 Transcript(s) of all coursework (Sealed)
 Test Scores (Original)
 Institutional Program Verification (Form #OEL 02-04, Sec.C)


___Five-Year Alternate Route License (Applies to graduates of a non-teacher education program who have met
all coursework and/or internship requirements of their alternate route program.)
 Licensure Application (Form #OEL 02-04, Sec.B)
 Transcript(s) (MAT program only)
 Certificate of Completion (MAPQT and TMI) or Institutional Program Verification (MAT) (Form #OEL 02-04,
    Sec.C)
   Mentorship/Induction Evaluation (MAPQT Program only) (Form# OEL 02-04, Sec.F)

                                           ADMINISTRATORS

___Administrator License / Non-Practicing
 Licensure Application (Form #OEL 02-04, Sec.B)
 Transcript (sealed)
 Institutional Program Verification documenting completion of an approved planned program in Educational
   Leadership/Supervision (Form #OEL 02-04, Sec.C)
 SLLA test scores (original)
___Administrator License / Entry Level
 Licensure Application (Form #OEL 02-04, Sec.B, Requested by Non-Practicing Administrators upon acceptance of
        employment as an administrator)
___Administrator License / Career Level
 Licensure Application (Form #OEL 02-04, Sec.B)
 Verification of School Executive Management Institute (SEMI) entry level requirements
                                                                             Form #OEL 02-04, Sec. A, page 3

                                                   DUPLICATES
___Requesting a Duplicate License
 Licensure Application (Form #OEL 02-04, Sec.B)
 $5 Money Order payable to MDE Office of Educator Licensure (No Personal checks accepted.)


                                    SUPPLEMENTAL ENDORSEMENTS
___Supplemental Endorsements (Only added to three-year and five-year licenses.)
 Licensure Application (Form #OEL 02-04, Sec.B)
      AND one of the following:
 Transcripts (Sealed) *In order to ensure accuracy and expedite your request, it is recommended that you submit new
        sealed transcripts of coursework in the specific endorsement area requested. Microfilmed records are sometimes
        unreliable.
             OR
   Original Praxis II Test Score or original CMEE Score (Taken prior to 5/26/2001)
             OR
   Documentation of completion of MDE approved Competency-Based Training Program
             OR
   Institutional Program Verification (Form #OEL 02-04, Sec.C) *Examples of endorsements requiring this form
    include Remedial Reading, Gifted, Computer Applications, Driver’s Ed., English as a Second Language, Health, Special
    Ed., Physical Science, Vocational Guidance, Cooperative Ed., and Business and Computer Technology.

                                        RENEWAL/REINSTATEMENT
___Renewal of Five-Year License
 Licensure Application (Form #OEL 02-04, Sec.B)
      AND
 Transcripts (sealed) AND/OR
 Original documentation showing completion of continuing education units (CEU’s) in
       content or job/skill related area. (Copies are not accepted) OR
 Documentation showing completion of National Board for Professional Teaching Standards
   process. (Documentation must be dated within the current renewal cycle.) OR
 Original documentation showing completion of 95 SEMI credits or completion of a specialist or doctoral
   degree in educational administration/leadership (Applies only to Career Level Administrators)

Please Note: All renewal coursework, CEU credits, National Board Documentation, or SEMI Credits must be dated within
the current renewal cycle. For example, if the current validity dates are 7/1/2004 to 6/30/2009, coursework must be taken
within those dates. Furthermore, if the current validity dates are in the future, renewal credits must be earned after the
beginning validity date.

___Reinstatement of Expired Five-Year License
   Licensure Application (Form #OEL 02-04, Sec.B)
        AND
   Transcript(s) (sealed), documenting required coursework for reinstatement
                                          OR
   Official document(s) verifying retirement from service in Mississippi public schools
                                          OR
   Original, valid, out-of-state educator license (Photocopies are not accepted.)
                                                                                         Form #OEL 02-04, Sec. B
                                                    Licensure Application
                                     (Must be LEGIBLY completed and submitted with all licensure requests.)
 Applicant Information
Social Security Number: _________ ______ _________

Name ___________________________________ ______________________________ __________________________
                            Last                                             First                                     Middle/Maiden
Address: ___________________________________________________________________                                        ______________________
                            Street/P.O. Box                                                                                   Apt.#
           _______________________________________________________________ _______                                        __________________
                           City                                                                                State           Zip
Phone Number____________________                      Birthdate___________________                               Gender______________
Ethnicity: (Ethnicity information is used for statistical purposes and to provide information required by the U.S. Department of Education in
                          accordance with applicable federal regulations. Your cooperation in providing this information is appreciated.)
     American Indian                         Alaskan Native                Asian                                      Black—non-Hispanic
     White—non-Hispanic                      Hispanic                       Pacific Islander                         Other

 Licensure Request
Class of license for which you are applying:                                                                                           Military
       ___A (Bachelor) ____AA (Master) ___AAA (Specialist) ____AAAA (Doctorate)                                                       Experience
      * Note: Any license with a validity period less than 5 years is issued at the Class A level.                                   (Check, if applicable)
                                                                                                                                     ___Army
Type of License (See Licensure Checklist for descriptive information.)                                                               ___USAF
     ___Approved Program/Teacher Education Route                    ___Duplicate                                                     ___Navy
         Subject Area (s): ____________________________             ___Reciprocity                                                   ___USMC
     ___Alternate Route                                             ___Renewal                                                       ___Reserve
         Subject Area (s): ____________________________             ___Reinstatement                                                 ___MSNG
     ___Supplemental Endorsement Subject Area(s) ______________________________________                                              ___Coast Guard
     ___Administrator License (Check level of license) ___Non-practicing ___Entry ___ Career
     ___Local District Request (Requested by Local District Only)___One Year License ___Expert Citizen



 Character Determination
Check “yes” or “no” to the left of each question. *If yes, submit official copies of court record including disposition of
case.
      ___yes___no   Are you currently addicted or currently dependent on alcohol?
      ___yes___no   Are you currently addicted or currently dependent on other habit-forming drugs?
      ___yes___no   Are you a habitual user of narcotics, barbiturates, amphetamines, hallucinogens, or
                    other dugs having similar effects?
      ___yes___no   Have you been convicted, pled guilty, or entered a plea of nolo contendere to a felony as defined by
                    federal or state law?*
      ___yes___no   Have you been convicted, pled guilty, or entered a plea of nolo contendere to a sex offense as defined
                    by federal or state law?*
      ___yes___no   Have you had a certificate/license denied, suspended, and/or revoked by another state? Have you
                    voluntarily surrendered a certificate/license?
*If you answered “yes” to any of the above, provide on a separate sheet of paper the specifics or an explanation for the response. If you
elect not to provide specifics or if such an explanation is insufficient, a confidential investigation will be initiated.

 I acknowledge that securing or attempting to secure a license by fraud or deceit will result in
 denial of this application or suspension of the license.

 Signature:__________________________________________ Date______________________
                                                                                    Form #OEL 02-04, Sec. C

                             INSTITUTIONAL PROGRAM VERIFICATION

   To the Applicant:
   Submit this form to the Dean of Education of the institution at which the program has been completed.
   Institutional Program Verifications are not required for all licenses. Institutional Program Verifications
   are required for the following:

     Administration                                Health Education           Gifted
     Computer Applications                         Physical Science           Cooperative Education
     Master of Arts in Teaching Program            Remedial Reading           Visually Impaired
     English as a Second Language                  Severe Disability (added to 221 only)
     Library Media (only if planned program)       Business and Computer Technology (added to 105 only)
     Vocational Guidance (added to 436 only)       Mild/Moderate Disability Program
     Occupational Child Care, Aging Services, Clothing, or Food Production Management
      (Each of the above added to 321or 322 only)

To the Dean of the School of Education:
Please complete this form and return to the applicant for inclusion in the application packet.

                                 INSTITUTIONAL PROGRAM VERIFICATION
                                (To be completed by the School of Education, if applicable.)
 This is to certify that, to the best of my knowledge, the applicant has satisfactorily completed the requirements
 prescribed by the State Board of Education and the laws of the state of __________________, has satisfied all course
 requirements, and demonstrates competence in the field(s) of ____________________________________________ for
 which the application for licensure is being made.

 ________________________________ _____________________________________                        ________________________
 Signature, Dean of Education or                College/University                                      Date
 Certification Officer




   * * * * * * * * * * * * * * * * * * * *
   For OEL Office Use Only
   (Applicant is not to write in this section.)

   License Number:_______________
   Class         Type                                          Class               Type


   Endorsement                                                 Endorsement


   Valid From:                  To:                            From:                               To:


   By:                          Date:                          By:                                 Date:



   Comments:
                                                                                          Form #OEL 02-04, Sec. D


                         VERIFICATION OF HIGHLY QUALIFIED STATUS
                                  (Required only for licenses requested by Reciprocity)

 To be completed by the applicant:
Name __________________________________________________________________________________________
                  Last                                Middle/Maiden                          First

Social Security Number ____________________________                    Date of Birth ___________________________

Mailing Address __________________________________________________________________________________

________________________________________________________________________________________________
                      City                           State                             Zip



 To be completed by an official of the Department of Education of the state issuing the
 license: Please return completed form to the applicant for inclusion in the application packet.
 The State of Mississippi requires that all applicants for licensure through Reciprocity be recognized as “highly qualified” as
 defined in the No Child Left Behind Act of 2001. Please complete the information below as verification that the individual
 holds “highly qualified” status in your state. Place the official state seal on the form and return it to the applicant for
 inclusion with his/her application packet.
           This certifies that the individual named above is deemed “highly qualified” in the state
         of ___________________________ for each of the following endorsements or subject areas:

   Endorsement or          Grade           Validity          Endorsement or               Grade             Validity
   Subject area:           Level(s)        Period            Subject Area:                Level(s)          Period




   Verifying Agency _______________________________________                                Please affix state seal:

   Address_______________________________________________
   ______________________________________________________
                City                     State   Zip
   Phone number __________________________________________

   Signature: __________________________________________________

   Title: _____________________________                    Date___________



                                                                                 Form #OEL 02-04, Sec. E
                             VERIFICATION OF ACCREDITATION
                                   CHILD DEVELOPMENT
                     (HB 419/Child Development – Required only for Child Development License.)

To be completed by the applicant:
Name _____________________________________________________________________________________
              Last                               Middle/Maiden                            First
Social Security Number _________________________                 Date of Birth ___________________________

Mailing Address ____________________________________________________________________________

               ____________________________________________________________________________
                     City                            State                      Zip



To be completed by the college or university:
This form is required only for Child Development license. Please complete and return to the applicant
for inclusion with the application packet.

       This is to verify that __________________________________________________________
                                                      (Full Name)
       Social Security # _____________________
       has completed a degree with Child Development emphasis from a program accredited by:

                            American Association of Family and Consumer Sciences (AAFCS)

                            National Association for Education of Young Children (NAEYC)




       __________________________________________________________________
       Division/Department


       _________________________________                         __________________________
       Name                                                      Date

                                       Mississippi Department of Education
                                          Office of Educator Licensure
                                                   P. O. Box 771
                                             Jackson, MS 39205-0771
                                                   601-359-3483




                                                                                   Form #OEL 02-04, Sec. F
                    MENTORSHIP / INDUCTION / EVALUATION FORM
               (Required only for applicants in the Mississippi Alternate Path to Quality Teachers Program.)


To be completed by the applicant:
Name_________________________________________________________________________________
                 Last                                First                            Middle/Maiden

Social Security #_______________________________                        Grade/Subject________________

School District ________________________________                        School Term _________________
Superintendent ________________________________                         Principal ____________________
Mentor ______________________________________

Applicant’s Signature ___________________________________________________

Note: The original of this form should be included in the licensure application packet. A copy of the form should be placed
in the applicant’s personnel folder.




To be completed by mentor teacher:
I have served as a mentor for the applicant named above during the current school term.


Mentor’s Signature :_______________________________________ Date:_______________________




To be completed by principal where applicant teaches:
I have provided an induction/mentorship program for the applicant named above. The evaluation of the applicant’s
performance is ____satisfactory _____unsatisfactory (check one).

Principal’s Signature: ____________________________________             Date:______________________


Note: The principal shall conduct one or more evaluations of the applicant’s performance, using the same evaluation tools
applied to the evaluation of all teachers. The principal shall then indicate if the applicant’s performance is satisfactory or
unsatisfactory.


**PLEASE NOTE: This original form is to be returned to applicant for inclusion in application
packet. A copy of the form is to be included in applicant’s personnel folder.




                                                                                          Form #OEL 02-04, Sec. G
                             VERIFICATION
            OUT-OF-STATE TEACHING/ADMINISTRATOR EXPERIENCE
                                    (Required only for licenses requested by Reciprocity.)



To be completed by applicant:
Name __________________________________________________               Social Security # _____________________
        Last           Middle/Maiden         First
Address ____________________________________       City, State, Zip _____________________________________

**NOTE: If your two years’ experience was split between two or more school districts, you may make a copy of this
form to send to each applicable district.




To be completed by Out-of-State School District Administrator and returned to the
applicant for inclusion in the application packet:
This is to certify that _____________________________________           Social Security # __________________
has successfully completed at least two years of teaching experience in our state:

Note: Teaching/Administrator Experience is defined as experience accrued by a properly licensed staff member in a grade or
subject under legal contract to an accredited public, private, elementary, or secondary (N-12) school; or
teaching/administrative experience accrued at a state-approved or regionally/nationally accredited Community/Junior College
or Institution of Higher Learning. Educational experience as an intern, graduate assistant, student teacher or in positions
such as substitute teacher, aide, or clerical worker, or experience accrued in Mississippi, will not be considered appropriate.

                           Start/Ending Date                    TOTAL            POSITION/         SCHOOL STATE
NAME OF SCHOOL             Mo/Day/Year                          YEARS            GRADE*            ACCREDITED?
                                                                                                   (Yes or No)
_________________          ______________________               _______          __________        ______________

_________________          ______________________               _______          __________        ______________


__________________________________________________                        ____________________________________
Signature of Superintendent, Principal, or Personnel Director             Position

__________________________________________________                        ____________________________________
Name of School District                                                   Date

__________________________________________________
Phone Number

* Examples: elementary teacher, biology teacher, elementary principal, superintendent, etc.

                                           Mississippi Department of Education
                                              Office of Educator Licensure
                                                       P. O. Box 771
                                                 Jackson, MS 39205-0771
                                                       601-359-3483