NDE 20-021
Revised 09-15
AGREEMENT STATEMENT
FOR A NEBRASKA TRANSITIONAL TEACHING PERMIT
This form must be submitted with a completed application form.
THIS FORM MUST BE COMPLETED EACH YEAR FOR ISSUANCE OF THE TRANSITIONAL TEACHING PERMIT. THE
PERMIT IS VALID ONLY IN THE NEBRASKA SCHOOL SYSTEM REQUESTING ISSUANCE
Agreement Statement of Superintendent or Governing Board of School System:
This school system intends to employ (Name) ___________________________________________
(Social Security #)* __________________________________ for the 20_______ to 20_______ school year.
Name and Address of School System: ___________________________________________________________________
__________________________________________________________________________________________________
**Signature of Superintendent or Authorized Representative Date
**If employed in a non-public school the signature of the area or diocesan superintendent is required.
Agreement Statement of
Applicant:
I understand that I must complete, at an approved teacher preparation program, at least 6 semester hours annually
towards completion of the Transitional Plan. In addition, I have agreed to meet the conditions set forth in the Contract for
Participation which is on file at the recommending teacher training institution.
Signature of Certification Officer
Date
*
The requirement that a certificate applicant provide his/her social security number is contained in Neb. Rev. Stat. 79-810. The uses that will
be made of this number are criminal background checks prior to issuance of a certificate and for purposes of data compilation and statistics
concerning employment of graduates of state approved teacher education programs and employment of certificate holders.
Signature of Applicant Date
Agreement Statement of
Certification Officer:
T
he following documentation is on file at the recommending teacher training institution for the above applicant:
To be completed for first issuance of the Transitional Teaching Permit:
Date
_____________ Statement regarding inability to hire fully qualified teacher for position
_____________ Written plan for mentoring and supervision
_____________ Transcript Review
_____________ Transitional Plan
_____________ Completion of Pre-Teaching Seminar
_____________ Signed Contract for Participation
To be completed for renewal of the Transitional Teaching Permit:
_____________ Six semester hours for renewal as identified on the Transitional Plan
_____________ Annual update of plan for mentoring and supervision
301 Centennial Mall South, PO Box 94987, Lincoln, NE 68509, Phone: 402-471-0739, Fax: 402-742-2359
Website: www.education.ne.gov/tcert Email: nde.tcertweb@nebraska.gov Twitter: @nde_tcert
