Free 46698.FH11 - Indiana

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APPLICATION FOR EMERGENCY PERMIT

State Form 46698 (R13 / 4-09) Approved by State Board of Accounts, 2009

DEPARTMENT OF EDUCATION OFFICE OF EDUCATOR LICENSING AND DEVELOPMENT 151 West Ohio Street Indianapolis, Indiana 46204 Telephone: (317) 232-9010 Toll Free number: (866) 542-3672 Fax: (317) 232-9023 www.doe.in.gov/educatorlicensing

ACCOUNTING CONTROL
Receipt number Date of receipt (month, day, year) Transaction number

IMPORTANT: A cashier's check or money order for $35.00, made payable to the State of Indiana, must accompany this application. DO NOT SEND CASH OR PERSONAL CHECKS. The information in this document is confidential according to IC 5-14-3-4(b)8. All fees are non-refundable. SECTION A - MUST BE COMPLETED BY SUPERINTENDENT - REQUEST FOR EMERGENCY PERMIT

As superintendent of _________________________________________________, corporation number ______________________, I have read the rules for Emergency Permits and certify that this corporation has been unable to secure a qualified licensed educator for the 20______ - 20______ school year. The requirements for the Emergency Permit have been met and I hereby request an Emergency Permit for the person named hereon in the licensing area of ______________________________________________________,
Content Area(s)

__________________________________________________.
School Setting(s)

Requested type of permit: Requested type of permit:

Original

Renewal Administration School Counselor

Instructional (Teaching)

The situation(s) leading to the application of this emergency permit are described as follows: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Accordingly, we wish to employ ______________________________________________________ for this vacancy.
Name of applicant

The applicants duties in this school

begin

began _________________________________________.
Date service started (month, day, year)

This individual best fills the needs of our school corporation because _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ All appropriate alternatives have been exhausted in the attempt to fill this position with qualified licensed personnel. I certify that I have seen a valid certificate from an approved provider verifying that the applicant has completed training in adult/child cardiopulmonary resuscitation that includes a test demonstration on a mannequin and removing of a foreign body causing an obstruction in an airway through the Heimlich maneuver. THE APPLICATION FOR THE EMERGENCY PERMIT MUST BE POSTMARKED WITHIN TWELVE (12) WEEKS OF THE APPLICANTS FIRST DAY IN THE ASSIGNMENT.
Name of Superintendent (type or print) Address of corporation (number and street, city, state, and ZIP code) Telephone number (with area code) Date (month, day, year)

(

)
E-mail address of superintendent

Signature of Superintendent

All correspondence regarding pending and denied applications will be conducted by e-mail.
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SECTION B - COMPLETED BY APPLICANT
Name (last, first, middle, maiden)

* This agency is requesting the disclosure of your Social Security number in accordance with IC 4-1-8-1(a), first paragraph, and with 42 USC 666(a)13. Disclosure is mandatory; this record cannot be processed without it. Address (number and street, city, state, and ZIP code)
Social Security number* E-mail address Degree(s) Telephone number (with area code)

Date of birth (month, day, year)

(

)

Institution(s)

Have you ever held any other type of Indiana teaching license, besides substitute?

Yes (attach copies)

No

Action requested:

Original Permit

Renewal (attach copy of previous permit)

SECTION C - CRIMINAL HISTORY AND LOYALTY AFFIDAVIT COMPLETED BY APPLICANT 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 Affidavit of probable cause Charging information Court records may be obtained from the clerk of the court(s). Plea agreements (if applicable) Judgment / Order of Sentencing Documentation of successful completion / release from any probation

If you answered Yes to question 3, you must submit a written explanation and any available documentation.
I certify that the information and documentation contained in my application, required for a license in Indiana, is true and accurate to the best of my knowledge and belief. Indiana law requires the applicant to sign the loyalty affidavit and to retain a copy. Please photocopy the completed application and keep a copy for your records. I solemnly swear (or affirm) that I will support the Constitution of the United States of America and the State of Indiana.
Signature of applicant Date signed (month, day, year)

SECTION D - FOR RENEWAL ONLY COMPLETED BY INDIANA LICENSING ADVISOR

No Emergency Permit will be renewed without the Licensing Advisor's signature. As Licensing Advisor of _______________________________________________________________, I certify that the teacher named hereon has completed the following six (6) semester hours of course work for renewal and is enrolled in an approved program to meet requirements for this license.
Name of institution

Signature of Licensing Advisor

Date signed (month, day, year)

Licensing Advisor: Please complete and sign ONLY if the applicant has completed six semester hours of course work in an approved program at your institution.

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Void License Number

Action Original Renewal

FOR OELD USE ONLY Basis: Rules 2002 Credential Type: Emergency Permit Corporation Number

Credential Category Instructional School Services Administration Degree Bachelor Master Specialist Doctorate

College/State

CONTENT AREA(S)

SCHOOL SETTING(S)

Date of issue (month, day, year) CPR Verification

Expiration date (month, day, year)

Date of Limited Criminal History report (month, day, year)

6 - 30 - ______
Initials of evaluator

Yes

No

Not needed
Rules and Policy for Emergency Permit Issuance Rules 2002
Emergency Permits: General Information

Emergency Permits may be granted as approved by the Division of Professional Standards, provided the following criteria have been met (Note: Applicants who are issued an emergency permit are not considered highly qualified unless they have earned a major and/or have successfully completed Praxis II in the content area.): Applications for the emergency permit shall be made through the employing school superintendent and include verification of an emergency need. The candidate holds a Bachelors Degree or higher from a state or regionally accredited institution. In addition to all instructional areas, emergency permits may be requested for school counselor and for the following administration areas: assistant principal, building level administrator, director of curriculum and instruction, director of career and technical education, director of exceptional needs and assistant superintendent. Candidates for administration emergency permits must have met the prerequisites for teaching experience and for the permit for principal or building level administrator; must have completed twelve (12) graduate semester hours of school administration course work. Candidates for all original permits must submit the completed form, Approved Program Confirmation Form for Emergency Permit Applicants with the signature of the licensing advisor and submit this form with the initial request for the emergency permit. Applications for the emergency permit must be postmarked within twelve (12) weeks of the applicants first day in the assignment. School districts may apply for the emergency permit after July 1 for the next school year. No applications for an emergency permit will be accepted after April 15 of the current school year. All emergency permits will have an expiration date of June 30 of the school year in which it is issued. A $35 money order must accompany ALL applications for emergency permits. Applicants may, but are not required to, complete the mentoring portion of the Indiana Mentoring and Assessment Program (IMAP). Mentors would be eligible for the stipend. If the applicant has an initial practitioner license in another area s/he may, but is not required to, complete the portfolio assessment portion of the IMAP program as well. Praxis II With an application for a Praxis II emergency permit, please include a copy of the applicants score report. Renewal All emergency permits may be renewed up to two (2) times for a specific content area. Emergency permits may be renewed upon the completion of six (6) semester hours. The licensing advisor at the institution must approve all renewal activities where the program is completed. Appeal Procedure The superintendent or designee must make all requests for appeals in writing to the Assistant Director of Licensing, Division of Professional Standards. Requests must explain in detail the emergency need and any pertinent details and circumstances surrounding the request.

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