Free 52649.FH11 - Indiana

APPLICATION FOR TRANSITION TO TEACHING PERMIT
State Form 52649 (R2 / 5-08) Approved by State Board of Accounts, 2008

DEPARTMENT OF EDUCATION OFFICE OF EDUCATOR LICENSING AND DEVELOPMENT 101 W. Ohio St., Suite 300 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 TRANSITION TO TEACHING As superintendent of ______________________________________________, school corporation number ______________________, I have read the rules and application guidelines for Transition to Teaching Permits, and certify that this corporation has been unable to secure a qualified licensed educator for the school year. The requirements for the Transition to Teaching Permit have been met and I hereby request a Transition to Teaching Permit for the person named in Section B. Three options exist for school corporations seeking an instructional Transition to Teaching Permit (please check the option requested): Option A. Thirty-six (36) school corporations may obtain a Transition to Teaching Permit for any instructional content area. The list of these school corporations and the list of instructional content areas are found on page 4. Content area requested: ______________________________________

Name of the school corporation: ___________________________________ School setting requested: ________________________________________

Any school corporation may obtain a Transition to Teaching Permit in any one of these shortage content areas: (Please check the content area and school setting requested.) School settings Content areas Mild Intervention Intense Intervention Blind and Low Vision Deaf and Hard of Hearing Mathematics Option C. Any world language Chemistry Earth / Space Science Life Science Physical Science Physics English as a New Language Technology Education Computer Education Pre-school (for Exceptional Needs only) Elementary Primary (for Exceptional Needs only) Elementary Intermediate (for Exceptional Needs only) Middle School / Junior High High School All Schools

Option B.

School corporations not listed in Option A may obtain a Transition to Teaching Permit in a non-shortage content area if they submit evidence on school letterhead of one or more of the following: 1. A change in student demographics requiring the school corporation to significantly change the instructional program. 2. A need for increased emphasis in the requested area to address learning gaps and improve student achievement as identified by ISTEP, AYP, and P.L. 221 results. 3. Proof that the school corporation is hard to staff as demonstrated by demographic data, including the complexity index of the school corporation, or the number or percentage of students in categories that are included in the complexity index. In addition to the application form and the evidence of one of the three criteria listed above, the school corporation will provide a written plan on how it will use the candidate.

Content area requested: _________________________________________
Name of Superintendent (type or print) Address of corporation (number and street, city, state, and ZIP code) Telephone number (with area code)

School setting requested: _____________________________________
Date (month, day, year)

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Signature of Superintendent

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)

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Institution(s)

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SECTION C - SUPERINTENDENT VERIFICATION FORM

I verify that our school corporation has a shortage or emergency need for personnel in the teaching area(s) of _____________________________________________.
Content area(s)

________________________________________________________
School setting(s)

The situation(s) leading to the application of this Transition to Teaching Permit are described as follows:

Accordingly, we wish to employ ________________________________________________________________ for this vacancy.
Name of applicant

SECTION C - SUPERINTENDENT VERIFICATION FORM

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.
Signature of Superintendent Corporation Date signed (month, day, year)

SECTION D - CRIMINAL HISTORY AND LOYALTY AFFIDAVIT COMPLETED BY APPLICANT Have you ever had a credential, certificate or license to teach denied, revoked or suspended in Indiana or in any other state? Have you ever been convicted of a felony? Have you ever been convicted of a misdemeanor other than minor traffic violations after January 15, 1994? Yes Yes Yes No No No

If the answer is Y to question 1, 2 or 3, attach a written explanation and provide court records. es
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)

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SECTION E - TRANSITION TO TEACHING VERIFICATION COMPLETED BY INDIANA LICENSING ADVISOR

No Transition to Teaching Permit will be issued without the Licensing Advisor's signature confirming the applicants acceptance into your institutions Transition to Teaching program for the content area(s) requested.

As Licensing Advisor of _______________________________________________________________, I certify that the teacher named
Name of institution

hereon has enrolled in an approved Transition to Teaching program to meet requirements for an Indiana license.

Name of teacher

Signature of Licensing Advisor

Date signed (month, day, year)

Licensing Advisor: Please complete and sign ONLY if the applicant is enrolled in a Transition to Teaching program at your institution.

CPR VERIFICATION Yes No Not needed

FOR OELD USE ONLY Gradation Transition to Teaching Permit 3 4 5 7

Degree Bachelor Master Specialist Doctorate

Basis Rules 2002

College / State

CONTENT AREA(S)

SCHOOL SETTING(S)

Corporation number

Date of issue (month, day, year)

Expiration date (month, day, year)

Date of limited criminal history report (month, day, year)

Initials of evaluator

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Rules and Policy for Transition to Teaching Permit Issuance Rules 2002
Transition to Teaching Permits: General Information
Transition to Teaching Permits may be granted as approved by the Office of Educator Licensing and Development, provided the following criteria have been met: Applications for the Transition to Teaching Permit shall be made through the employing school superintendent and include verification of an emergency need. The candidate holds the minimum of a Bachelors Degree from a state or regionally accredited institution. All Transition to Teaching Permits will have an expiration date of three (3) years after the issue date. A $35 money order, a valid Limited Criminal History report, verification of valid adult and child CPR / Heimlich maneuver certification from an approved provider, and an official transcript of the applicants highest earned degree must accompany ALL applications for Transition to Teaching Permits. Applicants may, but are not required to, complete the mentoring portion of the Indiana Mentoring and Assessment Program (IMAP). Applications for the Transition to Teaching Permit must include confirmation by an Indiana Licensing Advisor of admittance into an approved Transition to Teaching program. Transition to Teaching permits may not be renewed.

Eligible School Corporations for Option A (page 1)
Anderson Community Schools Blue River Special Education Corporation Carmel Clay Schools Diocese of Fort Wayne Diocese of Gary Diocese of Lafayette Schools Elkhart Community Schools Evansville-Vanderburgh Schools Fort Wayne Community Schools Gary Community Schools Goshen Community Schools Greater Clark County Schools Greenfield-Central Community Schools Indianapolis Department of Corrections Indianapolis Public Schools Joint Ed. Services Ind. Special Education Kokomo-Center Township Consol. Corporation LaPorte Community Schools Logansport Community Schools Madison Area Ed. Special Services Michigan City Area Schools Monroe County Community Schools MSD Lawrence Township MSD Perry Township MSD Pike Township MSD Warren Township MSD Wayne Township New Albany-Floyd County Consol. Corporation Northwest Indiana Special Education Coop. Office of Catholic Education Porter County Education Interlocal Richmond Community School Corporation School City of East Chicago School City of Hammond School City of Mishawaka South Bend Community Schools.

Instructional Content Area(s)
Business Education Career and Technical Education (please specify licensing area) Computer Education Driver and Traffic Safety Education Elementary: Intermediate Generalist Elementary: Primary Generalist English as a New Language ENL: Bilingual / Bicultural Exceptional Needs: Blind and Low Vision Exceptional Needs: Deaf and Hard of Hearing Exceptional Needs: Intense Intervention Exceptional Needs: Mild Intervention Fine Arts: Dance Fine Arts: Instrumental and General Music Fine Arts: Theater Arts Fine Arts: Visual Arts Fine Arts: Vocal and General Music Gifted and Talented Education (High Ability) Health Journalism Language Arts Library / Media Mathematics Physical Education Physical Education Adaptive PE Preschool Generalist Reading Reading Specialist Science: Chemistry Science: Earth Space Science Science: Life Science Science: Physical Science Science: Physics Social Studies: Economics Social Studies: Geographical Perspectives Social Studies: Government and Citizenship Social Studies: Historical Perspectives Social Studies: Psychology Social Studies: Sociology Technology Education World Language (specify languages) __________________________________ __________________________________ __________________________________

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