TE-4926 Rev. 11/03 AUTHORITY: Public Acts of 1976, as amended by Section 1531 of PA 230 (2000). COMPLETION: Voluntary (Certificate will not be issued if form is not filed).
Michigan Department of Education OFFICE OF PROFESSIONAL PREPARATION SERVICES P.O. Box 30008, Lansing, Michigan 48909
Direct questions regarding this form to (517) 335-0580.
APPLICATION FOR TWO-YEAR EXTENDED MICHIGAN PROVISIONAL TEACHING CERTIFICATE Pursuant to Section 1531(e) of PA 230 (2000), an expired Provisional Teaching Certificate may be renewed by the issuance of an Extended Provisional Teaching Certificate. Under the provisions of this section, a sponsoring school district or public school academy may apply to the Michigan Department of Education (MDE) on the person’s behalf for another Provisional Teaching Certificate within ten years after the expiration data of the person’s initial Provisional Teaching Certificate. The Extended Provisional Teaching Certificate is valid for two calendar years and is nonrenewable.
TEACHER INFORMATION SOCIAL SECURITY NUMBER
374 ___ ___
___ -- 82 ___
NAME
___
GENDER
Male
Last
x
Month
Middle
Kelly
Waigle
City
438 Redmond Dr.
State
Zip Code
MI
Blissfield
03/22/2000
Year Maiden
A
Street
ISSUE DATE OF INITIAL PROVISIONAL CERTIFICATE:
Day
11/06/1962
Female
First
Armstrong ADDRESS
DATE OF BIRTH
7439 -- ___ ___ ___ ___
EXPIRATION DATE OF INITIAL PROVISIONAL CERTIFICATE:
49228
06/30/2005
APPLICANT SCHOOL DISTRICT/SCHOOL INFORMATION LEGAL NAME OF DISTRICT/SCHOOL ADDRESS Street
School District of the City of Adrian
DISTRICT CODE (5 digits)
227 North Winter St.
46010
BUILDING CODE (5 digits)
00046
City
Adrian
TELEPHONE NUMBER (Area Code/Local Number)
State
MI
Zip Code
49221
(517) 263-2115
UNIVERSITY PROGRAM INFORMATION 1. University at which applicant is currently enrolled: _______________________________________________________ 2. Outline of planned program signed by representative of university is attached. 5.5 3. Teaching experience since issuance of initial provisional certificate: ____________ years
CERTIFICATION This application for a two-year, nonrenewable extended Provisional certificate is submitted on behalf and with consent of _______________ _________________________________. Completion of the attached planned course of study for a Professional Education certificate from an approved Michigan teacher preparation institution will be monitored by the district. Individuals who fail to complete all requirements for the Professional Education certificate during the two-year validity of the extended Provisional certificate will not be granted additional renewals of their initial Provisional teaching certificate. Applicant’s Signature _______________________________________________________________________
Date __________________________
Superintendent/Chief Official Signature ________________________________________________________
Date __________________________
--DO NOT WRITE BELOW THIS LINE— Grade Level ___________________
Date Approved _______________________
Examiner _____________________________________
SUBJECT FIELDS (Major, Minor, Endorsement)
(CODE “1” IF ALL GRADES)
Applications must be submitted to the above State address. THIS FORM MAY BE DUPLICATED.
