Certification Change

Please fill out this form to begin the licensure process in the Special Education Department.

Name Name First Last
Alternate Name Alternate Name First Last
Today's Date Today's Date / MM / DD YYYY
Phone Phone - ### - ### ####
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Do you presently have a degree?

Do you presently have a degree? Yes No
List ANY colleges/universities at which you have taken courses:
If your degree was in student teaching, list in which area:
Do you have an Illinois or other state teaching certificate?

Do you have an Illinois or other state teaching certificate? Yes No
If yes, which state?
List any endorsements held for teaching Special Education:
Are you interested in adding endorsements or removing the limited from your LBS I?

Are you interested in adding endorsements or removing the limited from your LBS I? Yes No
List any courses taken since obtaining your degree:
Years and months you have taught:
Subject(s) you have taught:
Grade Level you have taught:
Emergency Certificate:
1st Year teaching in SPE?

1st Year teaching in SPE? Yes No
Applied for Emergency Certificate?

Applied for Emergency Certificate? Yes No
Teaching on an emergency certificate?

Teaching on an emergency certificate? Yes No
Has a university signed your form?

Has a university signed your form? Yes No
If yes, please send us a copy to:

Department of Special Education
Eastern Illinois University
1212 Buzzard Building.
Charleston, IL 61920
If no, are you requesting us to sign?

If no, are you requesting us to sign? Yes No
Do you have your deficency statement from the Illinois State Board of Education?

Do you have your deficency statement from the Illinois State Board of Education? Yes No
If yes, fax us the most recent one.
Masters Program
Do you plan to pursue a Masters degree?

Do you plan to pursue a Masters degree? Yes No Unsure
Is a Masters degree ultimately your objective?

Is a Masters degree ultimately your objective? Yes No Unsure

Certification Change

Certification Change

Emergency Certificate:

If yes, please send us a copy to: Department of Special Education Eastern Illinois University 1212 Buzzard Building. Charleston, IL 61920

If yes, fax us the most recent one.

Masters Program

If yes, please send us a copy to:

Department of Special Education
Eastern Illinois University
1212 Buzzard Building.
Charleston, IL 61920