Fillable Application Type - EV EVALUATION, ADD-ON, COURSE APPROVAL (Teach Louisiana)

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Application Type - EV EVALUATION, ADD-ON, COURSE APPROVAL (Teach Louisiana)

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Page 1 (R
evised August 1, 2021)
Application Type - EV
EVALUATION, ADD-ON, COURSE APPROVAL & NAME CHANGE APPLICATION
By completing this application, educators may request degree/endorsement additions, course/transcript evaluations for the
purposes of fulfilling add-on, and course analysis/pre-approval. Upon receipt of the completed forms and appropriate
processing fee as noted on the Certification Processing Fee Schedule
, a certification case will be opened in the Teacher
Certification Management System (TCMS) which is trackable online. If additional information is needed or feedback is
provided, that information can be viewed online by checking the
Status of a Certification Application here. Evaluations will
be provided via the online portal in response to the certification submission case.
Adding a Degree(s)
To request the addition of a degree(s) to a certificate,
subm
it the application form, professional conduct form, transcript,
and certification processing fee receipt. Official transcripts should be sent (mailed or emailed) directly to you and will be
considered official when scanned and/or uploaded to online certification portal with your certification application packet.
W
hen requesting the addition of Master’s Plus 30 designation, excess graduate credits earned in the
m
aster's degree
program should be verified by the dean of the graduate school of the appropriate university. If there is a certification area
associated with the degree earned, the application should also include the request for that endorsement to be added to the
educator’s certificate; associated endorsements are not automatically added to the certificate.
Evaluation and/or Addition of Teaching Endorsements (Add-ons)
To request an evaluation and/or to add teaching endorsements to a teaching certificate, educators must conduct and submit
the applicable self-evaluation add-on checklist (located by clicking on the “Add-On Endorsement” link in the online portal
),
application, professional conduct form, transcripts, PRAXIS scores (if applicable), the experience verification form (if
applicable), and certification processing fee receipt. If you are uncertain as to the name of a specific certification area
offered in Louisiana, please refer to
Bulletin 746. If seeking certification as an Educational Leader (EDL), use the
Educational Leader Application to request EDL eligibility or the stand-alone certificate as it is NOT an add-on endorsement.
If seeking Mentor Teacher/Content Leader certification, use the Mentor Teacher/Content Leader (MT/CL) application.
Course Analysis and Approval
To request written pre-approval of coursework not yet taken for the purposes of certification endorsement add-on,
educators may apply for course analysis. The educator would include the application page, professional conduct form,
self-
evaluation add-on checklist (located by clicking on the “Add-On Endorsement” link in the online portal) indicating which
courses you wish to use to fulfill requirements, course titles/descriptions from university catalog or their website, and
certification processing fee receipt. Written feedback will be provided via the online portal in response to your request.
Name Change
To request a name change this application may be used by checking name change box on application page and by
providing a copy of the educator’s Social Security (SS) card and driver’s license showing legal name. Name changes are
included as a free transaction on all applications as the SS card and driver’s license are required with ALL certification
applications. If the name change is requested with no other transaction, the application page, professional conduct form,
the SS card, driver’s license, and a $25.00 fee are required.
Submitting the Application
Submit a completed application packet (including required documentation) through the online educator certification portal
.
The following items are required* as part of a complete application packet and must be signed and dated with current date:
1. Copy of Applicant Social Security Card and Driver’s License* (these are required with every application even if
name change is not requested)
2. “Certification Add-on, Evaluation, Course Approval (EV)” Application form*
3. Professional Conduct form with all questions answered, signed, and dated by the applicant*
4. Experience Verification form and/or Out-of-State Attestation form (if applicable)
5. Official tr
anscripts (if applicable and/or if not already submitted to the certification office)
6. Self-evaluation
Add-on Checklist (if applicable)
7. Copy of Online Payment Confirmation email or screenshot* - Use Processing Fee Schedule to determine amount
due. Payment is non-refundable and does not guarantee certification but is used for review of submitted documents.
Applicant will access the payment portal through the educator account on TeachLA Live! portal so that the fee,
appropriate to the request, can be made to LDOE.
Page 2 (Revised August 1, 2021)
Application Type - EV
Handwritten documents will not be accepted for certification processing.
Indicate the certification request/recommendation:
A
ddition of Degree(s)- (Enclose transcripts with application packet.)
Indicate Degree Adding:
University:
Date Degree Awarded:
Ma
ster’s Degree
Ma
ster’s Plus 30
G
raduate Hours
S
pecialist Degree
D
octorate Degree
Evaluate or Add the following endorsement(s)-
Endorsements should be listed as they officially appear in
Bulletin 746.
Self
-evaluation must be included with application packet.
Refer to the
fee schedule to determine total certification processing fee based upon the number of areas requested.
Course approval for the following endorsement(s)-
Endorsements should be listed as they officially appear in
Bulletin 746.
Self
-evaluation must be included with application packet indicating which courses you wish to use to fulfill requirements.
Course descriptions must be included with application pack
et (these can be from university catalog or their website).
Refer to the
fee schedule to determine total certification processing fee based upon the number of areas requested.
I agree that my typed/electronic signature as entered below is the legal equivalent of my manual signature on this application.
Signature of Applicant: Date:
Social Security Number ______________________ Email Address:__________________________________
Legal Name of Applicant:___________________________________________ Date of Birth:___________________
Check here if requesting name change; must match social security card & driver’s license submitted.
Address: _____________________________________________________________________________
(Street) (City) (State) (Zip Code)
Phone: (____) ________________ LA Certificate #: ____________ Payment Confirmation # __________________
(Provide email confirmation or screenshot of payment with documents)
---Select Certification Area Requesting---
---Select Certification Area Requesting---
---Select Certification Area Requesting---
Administration Endorsements Fulfilled Before completed by 12/31/2008
---Select Endorsement for Course Analysis Approval---
---Select Endorsement for Course Analysis Approval---
Professional Conduct Form
ANSWER ALL QUESTIONS
Check
YES NO
1. Have you ever had any professional license/certificate denied, suspended, revoked,
or voluntarily surrendered?
If YES, in which state?____________________________
2. Are you currently being reviewed or investigated for purposes of such action as stated
in #1 or is such action pending?
If YES, in which state?_____________________________
3. Have you ever been convicted of any felony offense, been found guilty or entered a
plea of nolo contendere (no contest), even if adjudication was withheld?
If yes, please provide the following information:
Date of Conviction: ____________________
State of Conviction: ________ Court Jurisdiction of Conviction: ______________________
4. Have you ever been convicted of a misdemeanor offense that involves any of the
following:
a. Sexual or physical abuse of a minor child or other illegal conduct with a minor child.
b. The possession, use, or distribution of any illegal drug as defined by Louisiana or federal
law.
5. Have you ever been granted a pardon or expungement* for any offense as stated in #3 or #4?
NOTICE---EXPUNGEMENTS, FIRST OFFENDER PARDONS, PRE-TRIAL DIVERSIONS: Criminal
Background Checks (CBCs) conducted for purposes of employment will be conducted in accordance
with La. R.S. 17:15 and La. R.S. 15:587.1. Pursuant to Louisiana law R.S. 15:587.1., background
checks shall disclose ALL ARRESTS, COURT ACTION and CONVICTIONS, (Including but not limited to
expungements, first offender pardons and pre-trial diversion), and a copy of the report shall be provided
to the Louisiana Department of Education (LDE), in addition to the potential employer or LA Education
Agency (LEAs)s.
*Per BESE policy set forth in Bulletin 746, Louisiana Standards for State Certification of School Personnel, Section 903.C,
“failure to disclose actions such as first offender pardons, pre-trial diversion, expungements, etc. is grounds for
certification denial and/or revocation.”
If you answered “YES” to any questions, #1 through #5, you must provide court certified copies of all documents and
proceedings, civil records of Federal, State and/or District School Board actions, or other relevant documents that provide
full disclosure of the nature and circumstances of EACH separate incident in your application packet.
I aff
irm and declare that all information given by me in the responses to items #1 through #5 above is true,
correct, and complete to the best of my knowledge. I understand that any misrepresentation of facts, by
omission or addition, may result in criminal prosecution and/or the denial or revocation of my teacher certificate.
I agree that my electronic, typed signature as entered below is the legal equivalent of my manual signature on
this document.
SIGNATURE OF
APPLICANT:
DATE SIGNED:
Rev. August 1, 2021
APPLICANT’S
LEGAL NAME:
SSN:
ADDRESS:
(Street Address, Including City, State, Zip)
DATE OF
BIRTH:
MM/DD/YYYY
(No
Dashes)
IN-STATE EXPERIENCE VERIFICATION FORM
This document is to be completed by the Louisiana employing school system as official verification of the
applicant’s work experience. The document is to be completed by typing into the form electronically.
Handwritten documents will not be accepted for certification processing.
Social Security Number: ______________________ Email Address:__________________________________
Legal Name of Applicant:___________________________________________ Date of Birth:___________________
Address: __________________________________________ Phone #: (_____) _________________
(Street) (City/State) (Zip Code)
I agree and verify the information contained in this document. My electronic signature, as entered
below, is the legal equivalent of my manual signature on this application.
SIGNATURE OF APPLICANT: DATE:
SIGNATURE OF EMPLOYING AUTHORITY: DATE:
TITLE & DISTRICT OF EMPLOYING AUTHORITY: EMPLOYER'S E-MAIL:
LA School
System
(Out of
State
Experience
must be
verified on
form linked
here)
NAME OF
SCHOOL
Type of
School
Dates of Service
(MM/YYYY- MM/YYYY;
E.g. 08/2018-06/2020 -or-
08/2019-current
Grade
Level(s)
Subject(s)
Taught or
Service
Provided
Role
(Teacher,
Substitute,
Principal, District
Leader, etc.)
Public
Non-Public
-
-
-
-
-
-
-
Rev: August 1, 2021
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Application Type - EV EVALUATION, ADD-ON, COURSE APPROVAL (Teach Louisiana)

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Completed 13 January 2022

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