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Revised July 1, 2013Virginia Department of EducationDivision of Teacher Education and LicensureP. O. Box 2120Richmond, VA 23218-2120APPLICATION FOR APROVISIONAL (SPECIAL EDUCATION)VIRGINIA LICENSEPLEASE NOTE: THIS APPLICATION MUST BE SUBMITTED BY A VIRGINIA PUBLIC SCHOOLDIVISION OR VIRGINIA ACCREDITED NONPUBLIC SCHOOL.Thank you for your interest in licensure in Virginia. Individuals seeking a Provisional (Special Education)Virginia License must apply for the license through an employing Virginia school division or Virginiaaccredited nonpublic school. Please follow the guidelines below, complete the application forms, attach allrequired documentation, and return all completed information in a single packet to the appropriate official inyour employing educational agency who will forward the application and supporting credentials to the VirginiaDepartment of Education.A complete packet must be submitted. If an incomplete packet is submitted and a license cannot beissued, the application and documentation will only be retained for one year. If a license has not beenissued within a year, a complete packet, including the fee will need to be submitted.Please follow the instructions below to apply for licensure.CRITERIA FOR SUBMITTING AN APPLICATIONFOR A PROVISIONAL (SPECIAL EDUCATION)VIRGINIA LICENSEYou may submit an application for the Provisional (Special Education) Virginia license through an employingVirginia school division or accredited nonpublic school if you meet the following criteria: Be employed by a Virginia public school division or accredited nonpublic school as a special educator andhave the recommendation of the employing educational agency; Hold a baccalaureate degree from a regionally accredited college or university; Have an assigned mentor endorsed in special education; Have a planned program of study in the assigned endorsement area, make progress toward meeting theendorsement requirements each of the three years of the license, and have completed coursework in thecompetencies of foundations for educating students with disabilities and understanding and application ofthe legal aspects and regulatory requirements associated with identification, education, and evaluation ofstudents with disabilities. A survey course integrating these competencies would satisfy this requirement.1
Revised July 1, 2013The Provisional (Special Education) Virginia License through this alternate route shall not be issued withoutthe completion of these prerequisites; and Have completed the child abuse recognition and intervention training and training or certification inemergency first aid, cardiopulmonary resuscitation (CPR), and the use of automated external defibrillators(AEDs).PLEASE NOTE:Provisional licenses are issued for a validity period not to exceed three years and may not be renewed orextended. Refer to Section § 22.1-299 of the Code of Virginia for individuals activated or deployed for militaryservice.PROFESSIONAL TEACHER’S ASSESSMENT REQUIREMENTSPlease refer to the Web site below to review required assessments for licensure in nsure/prof teacher assessment.pdfCHILD ABUSE RECOGNITION AND INTERVENTION TRAININGIS REQUIRED FOR INITIAL LICENSUREThe Code of Virginia requires that individuals seeking initial licensure and license renewal on and after July 1,2004, must complete study in child abuse recognition and intervention in accordance with curriculum guidelinesapproved by the Board of Education. Individuals must complete the Child Abuse Recognition and Interventionrequirement PRIOR TO LICENSURE.A training module, available at no cost, is accessible at the following Web ed reporters/cws5691/index.html. Be sure your computer isconnected to a printer when completing this training so you can print the certificate of completion. Submit thiscertificate with your completed application.TECHNOLOGY STANDARDS FOR INSTRUCTIONAL PERSONNELThe Code of Virginia requires that individuals meet the Technology Standards for Instructional Personnelapproved by the Board of Education. Individuals who graduated from an approved teacher preparation programin Virginia since December 1998 have met the requirement as the Technology Standards were incorporated inthe program. All other individuals will need to meet this requirement as outlined and verified by the employingVirginia educational agency.2
Revised July 1, 2013EMERGENCY FIRST AID, CPR, AND USE OF AEDsThe 2013 General Assembly amended the Code of Virginia to require that individuals seeking initial licensureand license renewal on and after July 1, 2013, shall provide evidence of completion of certification or trainingin emergency first aid, cardiopulmonary resuscitation (CPR), and the use of automated external defibrillators(AEDs). The Board of Education shall provide a waiver for this requirement for any person with a disabilitywhose disability prohibits such person from completing the certification or training.For additional information on this requirement, please refer to the question and answer document accessible atthe following Web site: tendents memos/2013/156-13a.pdf.PROCEDURES FOR APPLYING FOR A PROVISIONAL(SPECIAL EDUCATION) TEACHER'S LICENSEStep 1: Application Form: Please respond to all questions. SIGN AND DATE BOTH PAGES OF THEAPPLICATION. It is the applicant's responsibility to notify the Division of Teacher Education andLicensure in writing of changes in your mailing address. PART VII MUST BE SIGNED AND DATED BYTHE DIVISION SUPERINTENDENT OR ACCREDITED NONPUBLIC SCHOOL DIRECTOR.NOTICE: In accordance with § 63.2-1937 of the Code of Virginia, the Virginia Department of Educationrequires applicants for teacher licensure in Virginia to provide their social security numbers. Additionally,Virginia uses applicants’ social security numbers to check the clearinghouse maintained by the NationalAssociation of State Directors of Teacher Education and Certification (NASDTEC) for license revocation,cancellation, suspension, denial, and reinstatement in other states. Virginia also reports information to theclearinghouse as needed. The Virginia Department of Education will not release your social security numberexcept to the NASDTEC clearinghouse to report cases of license revocation, cancellation, suspension, denial,and reinstatement as noted above. Please note that if you do not provide your social security number, wewill be unable to process your request for a Virginia teaching license.Step 2: Nonrefundable Application Fee: Attach a certified check, cashier’s check, money order, or personalcheck made payable to the Treasurer of Virginia. The in-state fee is 50 and the out-of-state fee is 75.Note: The fee is determined by the address on your application. A 35 processing fee is assessed for acheck returned for any reason. Returned checks are subject to collection action.Step 3: College Verification Form: Send this form to the certification/licensure officer of the college oruniversity where you completed a state-approved teacher preparation program. The studentteaching/practicum/internship verification (Part III) must be completed for each studentteaching/practicum/internship experience. (If you have completed a state-approved program at theundergraduate and graduate levels, please have both institutions complete a form.)3
Revised July 1, 2013Step 4: Report on Experience: Request the completion of this form by the appropriate accredited nonpublicor public school division official(s) if you have completed at least one year of full-time contractual teaching orother school professional experience in early childhood special education or kindergarten through grade 12 at apublic or accredited nonpublic school.Step 5: Professional Teacher’s Assessment Scores: Please submit a copy of your scores for the licensureassessments required. Scores requested to be sent to the licensure office through the assessment company maynot arrive in this office through the electronic transfer process; therefore, it is necessary for individuals tosubmit copies of all scores to the licensure office. Please refer to the following Web site for testing icensure/prof teacher assessment.pdf. Individuals who hold a valid outof-state license (full credential without deficiencies) and who have completed a minimum of three years of fulltime, successful teaching experience in a public or accredited nonpublic school (kindergarten through grade 12)in a state other than Virginia may be exempted from the professional teacher’s assessment requirements.Step 6: Official Student Transcripts: Contact the registrar’s office of each college or university where youhave earned degrees or completed course work. Request official student transcripts to be sent to you, andsubmit the transcripts with your application packet. Official student transcripts (bearing the registrar’ssignature and embossed seal) that have been issued to students are acceptable. Placement records sent fromcolleges, grade reports, and photocopies of transcripts will not be accepted or returned.Step 7: Out-of-state License(s): Submit a photocopy of each of your current out-of-state license(s).Step 8: Certification of Child Abuse Recognition and Intervention Training: The Code of Virginiarequires that individuals seeking initial licensure and license renewal on and after July 1, 2004, must completestudy in child abuse recognition and intervention in accordance with curriculum guidelines approved by theBoard of Education. Individuals must complete the Child Abuse Recognition and Intervention requirementPRIOR TO BECOMING LICENSED. A training module, available at no cost, is accessible at:http://www.dss.virginia.gov/family/cps/mandated reporters/cws5691/index.html. Be sure your computer isconnected to a printer when completing this training so you can print the certificate of completion. Submit acopy of this certificate with your completed application.Step 9: Emergency First Aid, CPR, and AED Training or Certification: The 2013 General Assemblyamended the Code of Virginia to require that every person seeking initial licensure or renewal of a license shallprovide evidence of completion of certification or training in emergency first aid, cardiopulmonaryresuscitation, and the use of automated external defibrillators. The certification or training program shall bebased on the current national evidence-based emergency cardiovascular care guidelines for cardiopulmonaryresuscitation and the use of an automated external defibrillator, such as a program developed by the AmericanHeart Association or the American Red Cross. The Board shall provide a waiver for this requirement for anyperson with a disability whose disability prohibits such person from completing the certification or training.The following must be included on official documentation submitted to the licensure office by an individual: Individual’s full name (matching the name on licensure forms and the individual’s license, if applicable).Title or description of training or certification completed that must clearly indicate that all three componentswere included 1) emergency first aid; 2) CPR; and 3) AED.Date the training or certification was completed.Signature and title of the individual providing the training or certification OR printed certificate from theorganization or group that provided the training or certification. Legible copies of wallet-sized certificationcards or other sized certifications, containing the above information, from organizations providing current4
Revised July 1, 2013national evidence-based emergency cardiovascular care for cardiopulmonary resuscitation and the use of anautomated external defibrillator, such as a program developed by the American Heart Association or theAmerican Red Cross will be accepted.DEPARTMENT OF EDUCATION ADDRESSThe employing educational agency should submit the completed application and supporting documentation in asingle packet to:Virginia Department of EducationDivision of Teacher Education and LicensureP. O. Box 2120Richmond, VA 23218-21205
FOR OFFICE USE ONLYRevised July 1, 2013Virginia Department of EducationDivision of Teacher Education and LicensureP. O. Box 2120Richmond, VA 23218-2120APPLICATION FOR A PROVISIONAL (SPECIAL EDUCATION) VIRGINIA LICENSE (Page 1 of 3)APPLICATION FEE: Initial License (Fee: 50 in-state; 75-Out-of-state)Make checks payable to Treasurer of Virginia. The fee is nonrefundable. There is a 35 fee for a returned check.PART I--INFORMATIONSocial Security NumberPLEASE PRINT OR TYPEDate of Birth (Month/Day/Year)Last NameFirst NameMiddle NameSuffix (Jr., Sr., III, etc.)Address (Street, City, State, Zip Code) [Please note that the address provided is public information.]*Daytime Telephone Number (include area code)()Home Telephone Number (include area code)()Race (for statistical purposes only - check one)3. Black (not of Hispanic Origin)Gender (for statistical purposes only)MaleFemale1. American Indian/Alaskan Native2. Asian or Pacific Islander4. Hispanic5. White (Not of Hispanic Origin)*THE APPLICANT MUST NOTIFY THE OFFICE OF LICENSURE, DEPARTMENT OF EDUCATION, IN WRITING OF AN ADDRESS CHANGE.PART IIHave you ever been convicted of, or entered a plea of guilty or no contest to, a felony anywhere in the United States?(If yes, please attach a letter of explanation and a copy of the court documents indicating judgment and disposition of thecase from the court of conviction.)Have you ever been convicted of, or entered a plea of guilty or no contest to, a criminal offense in another country or a U.S.territory?(If yes, please attach a letter of explanation and a copy of the court documents indicating judgment and disposition of thecase from the court of conviction.)Have you ever been convicted of, or entered a plea of guilty or no contest to, a misdemeanor involving children (minor)?(If yes, please attach a letter of explanation and a copy of the court documents indicating judgment and disposition of thecase from the court of conviction.)Have you ever been convicted of, or entered a plea of guilty or no contest to, a misdemeanor involving drugs (not alcohol)?(If yes, please attach a letter of explanation and a copy of the court documents indicating judgment and disposition of the casefrom the court of conviction.)Have you ever had a teaching, administrator, pupil personnel services, or other education-related certificate or licenserevoked, suspended, invalidated, cancelled, or denied by another state, territory, or country; surrendered such a license; orhad any other adverse action taken against such a license?(If yes, please attach a statement giving full details and official documentation of the action taken.)Have you ever been the subject of a founded complaint of child abuse or neglect by a child protection agency?(If yes, please attach a statement giving full details and official documentation of the founded complaint.)Have you ever left any education or school-related employment, voluntarily or involuntarily, while the subject of aninvestigation, inquiry, or review of alleged misconduct or when you had reason to believe an investigation of allegedmisconduct was under way or imminent?(If yes, please attach a statement giving full details and any official documentation available regarding the investigation,inquiry, or review.)To your knowledge, are you currently the subject of any investigation, inquiry, or review of alleged misconduct that couldwarrant discipline or termination by a school division or other education-related employer or an adverse action against ateaching, administrator, pupil personnel services, or other education-related license or certificate?(If yes, please attach a statement giving full details and any official documentation available regarding the investigation,inquiry, or review.)YesNoYesNoYesNoYesNoYesNoYesNoYesNoYesNoBY MY SIGNATURE, I CERTIFY THAT THE INFORMATION ON THIS THREE-PAGE APPLICATION IS ACCURATE ANDCOMPLETE. I UNDERSTAND THAT MISREPRESENTATION MAY RESULT IN THE DENIAL, REVOCATION, CANCELLATION, ORSUSPENSION OF THE VIRGINIA LICENSE.DateApplicant’s SignatureThe application is continued on the following page. Pages 1, 2, and 3 of the application must include the applicant’s signature on each page. Acomplete application must be submitted. Incomplete applications may not be retained longer than one year.Page 1 of 3
Revised July 1, 2013Virginia Department of EducationDivision of Teacher Education and LicensureP. O. Box 2120Richmond, VA 23218-2120APPLICATION FOR A PROVISIONAL (SPECIAL EDUCATION) VIRGINIA LICENSE (Page 2 of 3)PART III--EDUCATION (Only colleges and universities--BA/BS and MA/MS)Name of InstitutionLocationDates AttendedDegree (if earned)Major/Major SubjectsPART IV--EXPERIENCE (Grades K-12 only -- Full-time, contractual experience only, not substitute, summer school, or aide)Name of SchoolLocationDates of EmploymentGrade(s)/Subject(s) Taught(Month/Year to Month/Year)PART V--OUT-OF-STATE EDUCATIONAL LICENSE – This section must be completed, if applicable. (Enclose a copy of each license.)State:First issue date:Last expiration date:State:First issue date:Last expiration date:State:First issue date:Last expiration date:PART VI--COMPLETE IF YOU HAVE ACCEPTED A POSITION IN VIRGINIA REQUIRING A LICENSEName of Employer :Beginning Date of Employment:Assignment:Address:BY MY SIGNATURE, I CERTIFY THAT THE INFORMATION ON THIS THREE-PAGE APPLICATION IS ACCURATE ANDCOMPLETE. I UNDERSTAND THAT MISREPRESENTATION MAY RESULT IN THE DENIAL, REVOCATION, CANCELLATION, ORSUSPENSION OF THE VIRGINIA LICENSE.DateApplicant’s SignaturePages 1, 2, and 3 of the application must include the applicant’s signature on each page. A complete application must besubmitted. Incomplete applications may not be retained longer than one year.Page 2 of 3
Revised July 1, 2013Virginia Department of EducationDivision of Teacher Education and LicensureP. O. Box 2120Richmond, VA 23218-2120PART VII – CERTIFICATIONS FOR A PROVISIONAL (SPECIAL EDUCATION) VIRGINIA LICENSEThe Provisional (Special Education) License is a three-year, nonrenewable teaching license issued to an individual employed asa special education teacher in a public school or accredited special education school in Virginia who does hold the appropriate specialeducation endorsement. The Provisional (Special Education) License is not applicable to individuals employed as speech pathologists.To be issued the Provisional (Special Education) License an individual must meet the following criteria: Be employed by a Virginia public or nonpublic school as a special educator and have the recommendation of the employingeducational agency;Hold a baccalaureate degree from a regionally accredited college or university;Have an assigned mentor endorsed in special education;Have a planned program of study in the assigned endorsement area, make progress toward meeting the endorsement requirementseach of the three years of the license, and have completed coursework in the competencies of foundations for educating studentswith disabilities and understanding and application of the legal aspects and regulatory requirements associated with identification,education, and evaluation of students with disabilities. A survey course integrating these competencies would satisfy thisrequirement. The Provisional (Special Education) Virginia License through this alternate route shall not be issued without thecompletion of these prerequisites.; andHave completed the child abuse recognition and intervention training and training or certification in emergency first aid,cardiopulmonary resuscitation (CPR), and the use of automated external defibrillators (AEDs).Please print or type:Name of School Division or Accredited Nonpublic Special Education School:Name of Teacher (First, Middle, and Last Name):Social Security Number of Teacher:Special Education Endorsement(s) Requested (The endorsement area requested must correspond to the teacher's assignment.):General Curriculum Adapted Curriculum Early Childhood Special Education Hearing ImpairmentsVisual ImpairmentsMentor Teacher Assigned to Teacher (The mentor teacher must be endorsed in special education.)Name: License No. or Social Security No.By my signature, I verify that I understand the criteria for eligibility for the Provisional (Special Education) License, and Iunderstand that I must complete the requirements for the license and endorsement (teaching) areas within the three-year validityperiod of the Provisional (Special Education) License.Signature of Teacher ApplicantDateBy my signature, I assure that the teacher requesting the Provisional (Special Education) License meets the criteria listed aboveand is the best qualified applicant for the position. I further certify that the school division has advertised the position and madereasonable efforts to recruit and hire qualified individuals. Documents of these assurances must be maintained in the schooldivision’s/school’s office.Signature of Superintendent/Director of Nonpublic SchoolDatePrinted Name of Superintendent/Director of Nonpublic SchoolPage 3 of 3
July 1, 2013Virginia Department of EducationDivision of Teacher Education and LicensureP. O. Box 2120Richmond, VA 23218-2120COLLEGE VERIFICATION FORMThe primary purpose of this form is to determine whether an applicant for licensure has completed a state-approvedpreparation program at the graduate or undergraduate level. In these cases, the form must be completed by the appropriatecertification/licensure official of the college/university where the program has been completed. The completed form must besubmitted to this office by the applicant along with other items required for licensure or the Virginia school administrator withwhom the applicant has accepted employment.PART ISocial Security Number:Date of Birth: (Month/Day/Year)Last NameFirst NameMiddle NameSuffix (Jr., Sr., III)Address (Street, City, State, Zip Code)Name of InstitutionDegree EarnedDate of Degree ConferralPART IIPlease circle the appropriate response:YESNOThe applicant satisfactorily completed a state-approved preparation program and completed endorsements(teaching areas, administration and supervision, or pupil personnel services) in the following areas:ENDORSEMENTS:PART III: Student Teaching, Internship, and/or Practicum Experience:Course Title: Course Number: Clock Hours:A.High School grade (s):(Do not include special education experience – use line C)B.Elementary grade (s):(Do not include special education experience – use line C)C.Specific special education area(s)* and grade level (s)*Please specify the exact nature of the exceptional child (children) included in the student teaching/practicum experience.Special subject area(s) (i.e., Art, Music, P.E.): Grade level (s):Requisite to compliance with the licensure regulations established by the Virginia Board of Education are the following conditions: theapplicant must be at least 18 years of age and must possess good moral character. By my signature, I certify on the basis of myinformation and belief that the applicant possesses good moral character. If I am signatory at a Virginia college or university, mysignature further certifies that the individual has met the following requirements: child abuse recognition and intervention training,technology standards for instructional personnel, certification or training in emergency first aid, cardiopulmonary resuscitation, and the useof automated external ON:
July 1, 2013Virginia Department of EducationDivision of Teacher Education and LicensureP. O. Box 2120Richmond, VA 23218-2120REPORT ON EXPERIENCEDIRECTIONS: A report verifying experience must be completed by the appropriate nonpublic school orpublic school division official if the applicant for initial licensure has had a total of at least one year offull-time, contractual teaching experience or held other professional positions in a public school oraccredited nonpublic school. The completed form must be submitted to this office by the applicant alongwith all other items required for licensure or to the Virginia school administrator with whom the applicanthas accepted employment.Last NameFirst NameMiddle NameSocial Security Number: - - or Virginia License #Address of Applicant (Street, City, State, Zip Code)NAME OF ACCREDITED SCHOOL(Please report only full-time, contractualteaching experience in an accredited public oraccredited nonpublic school. Experience as asubstitute teacher or aide should not be listed.)POSITION HELDGRADE LEVEL ORSPECIFICSUBJECT TAUGHTLENGTH OF SERVICE(MONTH/YEARTOMONTH/YEAR)Total number of years of full-time teaching experience:Total number of years of full-time experience in administration supervision:Total number of years of full-time experience in a pupil personnel services area(counselor, psychologist, social worker, speech pathologist, vocational evaluator):By my signature, I verify that the above-named person was successfully employed full-time, under contract inthe public schools or accredited non public school(s) and for the period(s) listed above.DATE:SIGNATURE:NAME:TITLE:SCHOOL DIVISION/SCHOOL:ADDRESS:
Richmond, VA 23218-2120 APPLICATION FOR A PROVISIONAL (SPECIAL EDUCATION) VIRGINIA LICENSE (Page 1 of 3) APPLICATION FEE: Initial License (Fee: 50 in-state; 75-Out-of-state) Make checks payable to Treasurer of Virginia. The fee is nonrefundable. There is a 35 fee for a returned check. PART I--INFORMATION PLEASE PRINT OR TYPE
