Free 46700.FH11 - Indiana

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APPLICATION FOR INDIANA SUBSTITUTE TEACHING PERMIT
State Form 46700 (R11 / 4-09) Approved by State Board of Accounts, 2008

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 Date received (month, day, year)

The information in this document is confidential according to IC 5-14-3-4(b)8. * 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.

INSTRUCTIONS:

1. 2. 3. 4.

Please TYPE or PRINT clearly. Attach money order or cashier's check for $15.00, 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.

Type of application

Original

Renewal

Duplicate

SECTION A - COMPLETED BY SUPERINTENDENT As Superintendent of ________________________________________________, Corporation number ___________________, I have submitted a Corporation plan for certifying substitute teachers for this Corporation. Under our plan, I hereby request a substitute certificate for the person named hereon, _________________________________________________________________.
Name of Superintendent (type or print) Address of corporation (number and street, city, state, and ZIP code) Signature of Superintendent Date (month, day, year) T elephone number (with area code)

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SECTION B - COMPLETED BY TEACHER
Name of applicant (last, first, middle) Social Security number * Address (number and street) City State ZIP code Date of birth (month, day, year) Maiden name T elephone number (with area code)

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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 Affidavit of probable cause Charging information 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)

Plea agreements (if applicable) Judgment / Order of Sentencing Documentation of successful completion / release from any probation