GPC-form
2/09/09
Graduate Program Confirmation Form
(for students seeking initial or advanced certification)
This form must be completed at the same time as the Form B/C and submitted to the Teacher Certification Office with the Form B/C.
Student’s Name: ______WKU ID# ______Phone: ______
Mailing Address: ______Email address: ______
Advisor’s Name: ______Department: ______
I presently hold certification in/for: ______
______
Please refer to your current teaching certificate and list all current certifications. If you are not certified, please write “no certification.”
I was/am admitted to the following graduate program: ______
This information may be found on TopNet. Advisors may find it at the General Student Information link. Students may find it by clicking on “Registration,” then on “View Student Information.” Please verify that the admission information is correct.
I wish to become/remain eligible for a federal student loan: ____ yes ____ no
I wish to complete the following program:
___ Master’s degree in ______
___ Planned Fifth-Year/Rank II in ______
___ EdS in ______
___ Planned Sixth-Year/Rank I in ______
___ Certification-only in ______
Upon completion of my present program, I wish to be eligible for the following certifications or endorsements (please check all that apply):
___ Rank II pay status
___ Rank I pay status
___ One or more of the following certifications/endorsements:
GPC-form
___ Provisional Guidance
___ Standard Guidance
___ Endorsement in Indiv Intellectual Assessment
___ Advanced Cert.: Elementary Ed
___ Advanced Cert.: Middle Grades Ed –
area: ______
___ Advanced Cert.: Secondary Ed –
area: ______
___ Initial Cert.: Middle Grades Ed (Alt Route) –
area: ______
___ Initial Cert.: Secondary Ed (Alt Route) –
area: ______
___ Endorsement in Teaching ESL
___ Endorsement in Gifted Education
___ Endorsement in Reading and Writing
___ Endorsement in Instructional Computer Tech
___ Endorsement in Environmental Education
___ School Principal (Level 1)
___ School Principal (Level 2)
___ Director of Pupil Personnel Services (Level 1)
___ Director of Pupil Personnel Services (Level 2)
___ Director of Special Education (Level 1)
___ Director of Special Education (Level 2)
___ Supervisor of Instruction (Level 1)
___ Supervisor of Instruction (Level 2)
___ School Superintendent
___ Initial Cert.: Exceptional Education – LBD
___ Advanced Cert.: Exceptional Education – LBD
___ Advanced Cert.: Exceptional Education – MSD
___ Initial Cert.: Interdisc Early Childhood Ed
___ Advanced Cert.: Interdisc Early Childhood Ed
___ Initial Cert.: School Media Librarian (for those with no other teacher certification)
___ Advanced Cert.: School Media Librarian (for those previously certified in ANY area)
___ Other: ______
GPC-form
Student’s Signature/Date: ______Advisor’s Signature/Date: ______