Free 46701.FH11 - Indiana

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APPLICATION FOR DUPLICATE OF INDIANA TEACHING, ADMINISTRATION, OR SCHOOL SERVICES LICENSE ONLY
State Form 46701 (R10 / 4-09) Approved by State Board of Accounts, 2007 The information in this document is confidential according to IC 5-14-3-4(b)8.

INDIANA DEPARTMENT OF EDUCATION Office Of Educator Licensing and Development 151 West Ohio Street Indianapolis, IN 46204 Toll Free: 1-866-542-3672 Fax: (317) 232-9023 www.doe.in.gov/educatorlicensing

ACCOUNTING CONTROL
Receipt number Transaction number

* This agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1. Disclosure is mandatory and this record cannot be processed without it.

This application may not be used for renewals or for duplicates of an expired license. INSTRUCTIONS: 1. 2. 3. 4. Please TYPE or PRINT clearly. Attach money order or cashier's check for $35.00, payable to the State of Indiana. Do not send cash or personal checks. All fees are non-refundable. Return this application with a Limited Criminal History report. ACTION REQUESTED
Check one of the following:

Degree change

Lost / destroyed license

Change internship

SECTION A - APPLICANT INFORMATION
Name of applicant (last, first, middle) Social Security number * Address (number and street, city, state, and ZIP code) Date of birth (month, day, year) Maiden name T elephone number

(

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E-mail address

SECTION B - LICENSE INFORMATION
Name (exactly as it appeared on License) License number Basis Type Action Date of issuance (month, day, year) Grade Subject area(s)

This license has been lost or destroyed. T the best of my knowledge, it was lost or destroyed in the following manner: o

SECTION C - CRIMINAL HISTORY 1. 2. 3. Have you ever been convicted of a felony? Have you been convicted of a misdemeanor since January 15, 1994? Have you ever had a credential, certificate or license to teach denied, revoked or suspended in Indiana or in any other state? Yes Yes Yes No No No

If you answered yes to questions 1 or 2, you must provide a written explanation and court records, including: Chronological case summary Plea agreements (if applicable) Affidavit of probable cause Judgment / Order of Sentencing Charging information Documentation of successful completion / release from any probation Court records may be obtained from the clerk of the court(s). If you answered yes to question 3, you must submit a written explanation and any available documentation. LOYALTY AFFIDAVIT I affirm that the information contained in my application is true and accurate to the best of my knowledge and belief. Misrepresentations made in this application may constitute grounds to deny, suspend, or revoke a license. I solemnly swear (or affirm) that I will support the Constitution of the United States of America and the Constitution of the State of Indiana.
Signature of applicant Date (month, day, year)