Fill and Sign the Redd Partnership Voluntary Redd Database Progress Report Ksrevenue Form

Board of Educational Examiners Licensure Grimes State Office Building 400 E. 14th St. Des Moines, Iowa 50319-0147 APPLICATION FOR LICENSURE (IOWA INSTITUTION) office use only Rev 10/12 I. TO BE COMPLETED BY APPLICANT (type or print) Applicant’s Folder # Please allow four weeks for processing. Incomplete applications will be voided after 45 days Social Security # Date of Birth Month Day Year Male Female First Name Middle Name Maiden Name City Last Name State Zip Code Name changes official documentation. Address Evening Phone Daytime Phone ( ) ( ) Degree(s) held and conferred: Bachelor's Date License Desired: Initial ($85) Substitute ($85) Email Address Master's Institution Date Institution (Make check or money order payable to the Board of Educational Examiners) Background Check: I have included my fingerprint cards, waiver forms, and $65 background check fee My fingerprint cards, waiver forms, and background check fee have already been submitted Additional Background Information: Attach a written explanation on 8 1/2" x 11" paper for any "Yes" response to questions “a” to “e.” Be sure to include the date of the violation. DO NOT explain on this application form. If you have reported a "Yes" response on a previous application, check “PR” (previously reported) instead of "Yes" on this application if no further conviction(s) has occurred. No PR Have you ever been convicted of a felony? a. Yes No PR Have you ever been convicted of a crime other than parking or speeding violations? (Include all deferred judgments) b. Yes No Do you currently have any criminal charges pending against you? c. Yes No PR Have you ever had a founded report of abuse made against you? d. Yes No PR Have you ever had an educational license denied, revoked, or suspended? e. Yes No Are you a United States citizen? f. Yes If you answered “No,” check if you are: a qualified alien (as defined in 8 U.S.C.A. § 1641). If so, please provide appropriate documentation. an alien who is paroled into the United States under 8 U.S.C.A. § 1182(d)(5) for less than one year. (If so, please provide appropriate documentation.) a foreign national not physically present in the United States. other – Please provide a detailed explanation on a separate 8 ½ x 11 sheet of paper. Statement of Fraud: An application will be considered fraudulent, and may be denied, if it contains any false representation or omission of material fact, or if false records are submitted in support of the application. I certify under penalty of perjury and pursuant to the laws of the state of Iowa that the preceding information is true and correct. I hereby give permission for the Board of Educational Examiners to conduct both an Iowa criminal history record check with the Division of Criminal Investigation and a national check through the Federal Bureau of Investigation. Any information maintained by the DCI or the FBI may be released as allowed by law. ______________________________________________ _____________________________________________ Signature of Applicant Date SECTION II - Endorsement: to be completed by institution Include $50 for each endorsement being added to an existing license. (payable to the Board of Educational Examiners) After our transcript analysis, we find that the applicant has completed this institution's approved program for adding the following endorsements: After our transcript analysis, in lieu of our approved program, we find that the applicant has completed the BOEE's requirements for adding the following endorsement(s). ______________________________________________ _____________________________________________ Signature of Recommending Official Institution Name ______________________________________________ ______________________________________Seal Here Typed or printed Signature of Recommending Official Date Affix College