Application for Teacher Certification

APPLICATION FOR DEGREE/CERTIFICATION

COLLEGE OF EDUCATION

Date________________

NAME

Last First Middle

Address

Street City, State Zip Code

Social Security Number Student ID Number Home Phone Number

Email Address Cell Phone Number Work Phone Number

Male ___ Female ___ Bachelor Degree___ or Teacher Certification___

Expected Date of Graduation/Certification:

May_________ August_________ December_________

(year) (year) (year)

Program:

___ Early Childhood B-3 ___ Middle School Math 5-9 ___ Special Education K-12

___ Elementary 1-6 ___ Middle School Lang Arts 5-9 ___ Physical Education K-9

___ Middle School S.S. 5-9 ___ Middle School Sci 5-9 ___ Physical Education K-12

___Bachelor of Educational Studies

Secondary 9-12 – Subject _______________________________________________________________

Are you presently enrolled in courses off UM-St. Louis Campus? No_____ Yes_____

(This includes Correspondence Courses.)

If so, please list__________________________________________________________________________

Course College/University Semester

LIST ALL COLLEGES ATTENDED ________________

*Your name will appear on your diploma as it does on your grade reports. If you wish to change it, contact the Admission Office.

FOR TEACHER CERTIFICATION & ADVISING OFFICE USE ONLY.

Praxis II Specialty Area Test ____________ ____________

(Number) (Score) 12/8/11