Please Attach This Form to Your Application

Application Cover Sheet

Please attach this form to your application

I am submitting my application for consideration for admission to a...

Route 2 program—residency certification with endorsement(s) in (check all applicable):

Bilingual Education

Biology

Chemistry

E.S.L.

Mathematics

Middle Level Math

Middle Level Science

Physics

Special Education

World Language(s)

Specify Language:

Other (please verify with program coordinator before completing):

Route 3 program—residency certification with endorsement(s) in (check all applicable):

Bilingual Education

Biology

Chemistry

E.S.L.

Mathematics

Middle Level Math

Middle Level Science

Physics

Special Education

World Language(s)

Specify Language:

Other (please verify with program coordinator before completing):

Route 4 (teaching with a conditional certificate) seeking a residency certificate with

endorsement(s) in (please verify with program coordinator before completing):

For everyone applying please fill out the following questions

I passed the W.E.S.T. B (attach verification).

If you have not passed this test, indicate the date on which you are register to take the test:

I passed the W.E.S.T. E (attach verification)

In what content area(s) have you taken the test(s)?:

If you have not passed this/these tests, indicate the date on which you are registered to take this/these tests:

I have read the attached letter regarding conditional loan scholarships and understand the eligibility requirements and conditions for which the loan shall be forgiven.

Signature: Date:

Application Information

Due April 8th 2011

General Information
Last Name / First Name / Middle Initial
Phone
( ) - / SSN
- -
Former Names
Last Name / First Name / Middle Initial
Permanent Address
Street Address
City / State / Zip Code
Mailing Address
Street Address
City / State / Zip Code
Education (degree must be from a regionally accredited institution for admission)
Highest Degree / Name of University
Endorsement Area(s)
W.E.S.T. tests
Date of W.E.S.T. B / Passed? / If ‘no’ date of scheduled/planned retake?
Date of W.E.S.T. E / Passed? / If ‘no’ date of scheduled/planned retake?
Content areas W.E.S.T. E taken?
Education Experience
Currently employed in a school district? Yes No
If Yes, which school and district? / Experience in educational setting? How many years?

REMINDER: Both WEST-B and WEST-E (all content areas for which you are seeking an endorsement) must be taken AND passed, with results for both submitted, to the begin the summer module classes.

List all REGIONALLY ACCREDITED colleges and universities attended

Institution name
Is this institution regionally accredited? / Degree Received? BA/BS Master’s Doctorate
Major:
Minor:
Institution name
Is this institution regionally accredited? / Is this institution regionally accredited?
Institution name
Is this institution regionally accredited? / Is this institution regionally accredited?

Optional Demographic Information

Male

Female

Date of Birth: Month Date Year

How would you describe yourself/your ethnic/racial background?

African American

Asian American/Pacific Islander

Caucasian/White

Hispanic/Latino (a) American

Native American/Alaska Native

Multiethnic

Other Please Describe

I certify that to the best of my knowledge, all statements I have made in this application are complete and true

Signature: Date:

Checklist For Complete Application Packet

Applications for the 2011-2012 Cohort will be accepted until April 8, 2011. A complete application includes all of the following...

Signed application cover sheet

Application form

Cover letter indicating career goals, intended endorsement area, teaching level

of interest, and verification of willingness to participate in a Summer

Academy and full-time internship during the 2011-2012 school year

Resume

Two letters of recommendation which include one of the following...

Verification of one year of successful student interaction and

leadership (Route 2 only)

Verification of one years of career experience (i.e., accountant,

chemist, conditional certified teacher) (Routes 3 & 4 or mid-

career professionals/individuals employed with conditional

certificates/emergency substitutes)

Passing WEST-B scores submitted to Dr. Lynn prior to June 1, 2011

Passing WEST-E scores submitted to Dr. Lynn prior to June 1, 2011

Official transcripts from all regionally accredited institutions (showing GPA of 2.5 or higher)

Form 4020 B character and fitness form

(Found at www.k12.wa.us.certification)

All this information must be submitted to…

Dr. Rexton Lynn, Coordinator

CWU-Yakima

P.O. Box 22520

Yakima, WA 98907-2520

(Delivering by hand? Bring materials to YVCC, Deccio Building, Room 107)