Application for Admission to Teacher Education
Albany State University Educator Preparation Program
Candidates please follow all steps below to complete your application.
Incomplete applications will not be accepted.
STEP 1:
Create My PSC and GACE.ETS Account (see attached instructions on how to set-up
account)
STEP 2: Register for GACE Program Admissions
MyPSC account and select Assessments at the top of the
MyPSC home page. Follow the steps below to request or confirm eligibility to
test:
2. Select the reason why you want to take the GACE assessment (see below).
a. GACE Program Admissions
1. Log in to your
Select reason #1
#1 I am testing to satisfy the
You must add the program you are enrolled
Program Admission assessment
in or seeking admission into as a score
requirement.
recipient.
b. GACE Content only: If you are enrolled in or have completed an
approved program, you will see the list of programs and providers
where you have claimed enrollment and your status for your eligibility
to test for the program(s). If you do not see any programs and
providers listed, it means you have not claimed your enrollment. See
Claiming Your Enrollment Record below.
3. Select the assessment for which you are requesting eligibility to test from the
drop-down menu.
4. Click the ADD button.
5. Confirm your choices by typing “yes” in the space provided and then
click FINISH. (You can click QUIT to cancel your selection.)
6. Your profile and eligibilities will be transmitted to ETS.
7. At the bottom of the Assessments page is a list of your active and pending
eligibility requests and their status. Note: Program providers are notified via
email of pending requests for eligibility.
Teacher Education ATE Application Package Revised: November 2016 LJ
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STEP 3:
Register for GACE Ethics Entry (350)
All updates to your information must be completed through your MyPSC account on
the GaPSC website prior to registering for the assessment.
How to Register
Registering for one of the Georgia Ethics assessments is a four-step process:
1. Create or update your MyPSC account on the GaPSC website and enter your
reason for testing.
2. The GaPSC sends your profile and eligibility information to ETS.
3. ETS sends you an email with a link to the Georgia Ethics assessment system.
4. Access the Georgia Ethics assessment system, select Test Takers under
Registration, create your account, and register and pay for the assessment.
Program Entry candidates: You must add your program provider as a score recipient
when you register or they will not receive notification that you have completed the
assessment.
There are no specific testing dates or testing windows for the Georgia Ethics
assessments, but you must create or update your MyPSC account and enter
your reason for testing before you can register.
You are responsible for ensuring that the first and last name in your MyPSC
account match the name you enter in the Georgia Ethics assessment system. The first
and last name in this account will be on your certificate of completion for the
assessment.
STEP 4: Submit application for review
Meet with assigned advisor to review the application & make revisions as
necessary
Advisor will submit application to Office of Teacher Admission
NOTE: Applications will be accepted only from academic advisors
Teacher Education ATE Application Package Revised: November 2016 LJ
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The Admission to Teacher Education
Application Package
Assemble in the following order:
Application (Check Front and Back)
Practitioner Demographic Data (Front Only)
Candidate Self Evaluation (Front Only)
Code of Ethics (Front and Back)
Essay Analysis and Critique Rubric (Name and Ram ID)
Two Recommendation Forms from (Front Only)
Transcripts (2.50 GPA)
GACE Program Admissions Scores OR substitute scores, SAT, ACT,
GRE, Praxis
Criminal Background Check application
o NOTE: You must pass the Criminal Background Check every
semester you are enrolled in 3000-4000 level classes in order to
maintain your status as a Candidate in the Teacher Education
Program.
GACE Ethics Entry Exam Certificate (Beginning Fall 2014)
Pre-Service Certificate Application completed (Beginning Fall 2014)
Copy of Driver’s License or ID
Liability Insurance i.e. GAE or PAGE student membership (copy)
Professional Disposition Statement signed by student.
Teacher Education ATE Application Package Revised: November 2016 LJ
Page3
Candidate Requirement
Step 1: Create MyPSC Account
Go to the link below and register for a My PSC Account
https://mypsc.gapsc.org/Register.aspx
Select: “Enrolled in Georgia Educator Preparation Program”
Select: “To take GACE assessment”
o Certification Identification # will be provided; keep this number for your
records. You will also need it to create GACE Testing account.
Step 2: Create GACE Testing Account
Register for an ETS GACE Test account. This allows you to take the GACE Program
Admission, Ethics, and GACE Content test (Must have My PSC account first before
create GACE Testing account)
Click here to create account www.GACE.ets.org
Select “Sign-In” (top right of website)
Go to “New User” area
Select “Create Account”
Save log-in credentials
Register and complete Program Admissions Test (Reading, Writing, Math) Assessment;
Dates and times test is available will be shown when you register
Print a copy of passing scores and submit with application
Register and Complete GACE Ethics Entry
Assessment is anytime and anywhere
Assessment cost $30
Print Certificate
of Achievement and submit with application
Teacher Education ATE Application Package Revised: November 2016 LJ
Page4
APPLICATION FOR ADMISSION TO THE EDUCATOR PREPARATION PROGRAM
Applicant Information Must be admitted to ASU
RAM I D
Name
ADDRESS
State:
ZIPCODE:
E-MAIL
HOME PHONE
CERTIFICATION INFORMATION CHECK ALL THAT APPLYCcc
MYPSC.COM ID #
AREA:
SEEKING
MIDDLE EDUCATION (Place a
for your PRIMARY-P and S
SECONDARY for
CONCENTRATION)
LANGUAGE ARTS
MATH
SCIENCE
SOCIAL STUDIES
DEGREE
MINOR IN EDUCATION NON-
CERTIFIED
CERTIFICATION ONLY
T4-BACHELOR
T5-MASTERS
REQUIREMENTS (Attach documents of verification for all applicable items below.)
1. _______ENGL 1101 12. ______Pre-Service Certification Application
2. _______ENGL 1102 13. ______Copy of Driver’s License or ID
3. _______EDUC 2110 14. ______Letters of Recommendation (2) From any
4. _______EDUC 2120 current or former ASU Faculty
5. _______EDUC 2130 15. ______Applicant Self Evaluation
6. _______ASU Hours Earned 16. ______Applicants Essay
7. _______Institutional GPA 17. ______Criminal Background Check Application
8. _______Transfer GPA 18. ______GACE (Reading, Writing, Math) Program
9. _______Transfer Hours Admissions Scores (250 passing) or IF GACE
10. _______Program of Study/Checksheet EXEMPTION: ACT 43 MATH/ENGLor
11. _______GACE Ethics Entry Exam
SAT 1000 VERBAL/MAT
Advisor Signature: _______________________________________________________________ Date: _________
(I have reviewed and verified evidence for Performance Measures in Performance Measures in
Part III)
FOR ADMISSION TO TEACHER EDUCATION OFFICE USE ONLY
Approved by ____________________________________________________________ Date______________
Teacher Education ATE Application Package Revised: November 2016 LJ
Page5
APPLICANT
ADVISORS
EADLINE FOR SUBMISSION OF APPLICATION PACKET
APPLICATION PROCESS
THE ADMISSION OFFICE OF THE EDUCATOR PREPARATION PROGRAM RESERVES THE RIGHT TO CHANGE PROVISIONS
LISTED IN THE CATALOG AND OTHER STUDENT-INFORMATION DOCUMENTS IN ADHERENCE TO CHANGES MANDATED
BY FEDERAL, STATE AND LOCAL AGENCIES THAT GOVERN TEACHER EDUCATION PROGRAMS
The application forms are available in The Admission Office of the Educator Preparation Program, Billy C. Black
Building, Room 252. The applicant must initiate the application process by completing the information in Part I, Part
II, and Part III (if applicable) of the application, attaching verification documents for each section, and presenting
the complete packet to the assigned advisor.
Advisors facilitate the application process to ensure that the application is signed and complete the application.
Advisors should submit the applicant’s packet to the Coordinator of Admissions to Teacher Education.
CERTIFICATION OFFICER FOR TEACHER EDUCATION
The Certification Officer for the Educator Preparation Program approves or denies applications. If denied, the
Certification Officer will return the application packet, with explanation, to the Advisor within five working days of
receipt of the application packet. Upon approval the Certification Officer provides the applicant a letter of
admittance by ram e-mail.
The applicant must initiate the application process one semester prior to the semester in which they expect to enroll
in 3000 or 4000 level Teacher Education courses.
GPA
A GPA of 2.50 or above must be maintained for good standing in the Teacher Education program and is required
for certification and Graduation You must have a 2.50 GPA to participate in Student Teaching or Internships. A GPA
of 2.75 or better is required for Second Chance applicants. .
BEGINNING SCHOOL EXPERIENCE
All students are required to spend two weeks in a public school to observe/participate at the beginning of the
school year. Students must apply for the beginning school experience during the spring semester prior to the
academic year they are scheduled to student teach, whether student teaching in the fall or the spring. They must
complete this non-paid volunteer experience as a staff member in a public school setting. Approval and
arrangements for the beginning school experience are made with the public school by the Director of Clinical
Experiences. Service for one year as a paraprofessional may substitute for the beginning school experience.
EDUC 3403: PREPARATION FOR TEACHING
Approval from the ASU coordinator of student teaching is required for enrollment in this class. Students should take
this course in THE SEMESTER before STUDENT TEACHING or INTERNSHIP. You must pass your Criminal Background
Check and maintain the 2.50 GPA in order to Student Teach or Intern.
All Candidates must pass all areas of the GACE in their program of study prior to Graduation.
EDUC. 2199 Orientation to Teacher Education
Candidates will be enrolled in this course upon acceptance and must complete the course in order to remain in
the Teacher Education Program.
I read and understand the above policy statements about the procedural process for admittance to the Teacher
Education Program at Albany State University.
Applicant’s signature: _____________________________________________ Date: ____________________
Teacher Education ATE Application Package Revised: November 2016 LJ
Page6
Practitioner Demographic Data
Directions: Please select the appropriate choice from the following items.
Certification Level:
P-5
4-8
7-12
BS Ed. T-4
MS Ed T-5
Area(s) of Certification
English Education
Early Childhood Education
Math Education
Middle Grades Education
Broad Field Science Education
Social Science Education
Special Education
Interrelated/ M Ed
Intellectually Disabled BS Ed
Other:
Science Education
Health and Physical Education
Music Education
Other School Personnel
Principal
Assistant Principal
School Counselor
Age:
Under 21
DOB: ___________
Gender:
21-30 31-40 41-50 51-59 59+
Ethnicity:
Male Female
White/Non-Hispanic
Hispanic
Black/Non-Hispanic
American Indian or Alaskan Native
Asian/Pacific Islander/East Indian
Multi-ethnic
Teacher Education ATE Application Package Revised: November 2016 LJ
Page7
Candidate Self-Evaluation
Rating scale: 1 Unacceptable 2 Acceptable 3 Targeted
Score
Commitment to students and their learning.
1. I exhibit personal and professional integrity.
1 2 3
2. I respect the learners he/she teaches.
1 2 3
3. I provide multicultural learning environments.
1 2 3
4. I hold high expectations for all learners.
1 2 3
5. I respond appropriately to the needs of each individual learner.
1 2 3
6. I create learning environments that support the development of every learner.
1 2 3
Knowledge & Skills
7. I demonstrate knowledge of the content required for his/her teaching area.
1 2 3
8. I use appropriate oral and written language skills to communicate content.
1 2 3
9. I implement effective instructional practices.
1 2 3
10. I use technology to support learning experiences for students.
1 2 3
Managing and monitoring student learning.
11. I design instruction that is guided by principles of human growth and development
1 2 3
that is appropriate for all learners.
12. I design instruction that is guided by the Georgia Quality Core Curriculum and/or other
appropriate standards.
1 2 3
13. I design instruction that incorporates parental involvement of all learners.
1 2 3
14. I use multiple methods of assessing student learning.
1 2 3
15. I recognize the characteristics of children with exceptional needs and follows
appropriate processes for student referrals.
16. I attain student achievement goals on specified learning outcomes.
1 2 3
1 2 3
Personal Reflection
17. I use feedback to improve on learning and practice.
1 2 3
18. I participate in opportunities for further professional development.
1 2 3
Community Service
19. I volunteer to assist with the unique needs of local families and the learning
1 2 3
community.
1 2 3
20. I volunteer to work with programs that seek to improve children’s academic skills.
Comments:
Total_____________
Teacher Education ATE Application Package Revised: November 2016 LJ
Page8
www.gapsc.com
F.D. Toth, Executive Secretary
Georgia Professional Standards
Commission
Two Peachtree Street, Suite 6000
Atlanta, GA 30303-3141
Gary Walker, Director
Educator Ethics Division
404-232-2700
800-537-5996
Fax: 404-232-2720
ethica@gapsc.com
THE CODE OF ETHICS FOR EDUCATORS
Effective June 15, 2015
Introduction.
The Code of Ethics for Educators defines the professional behavior of educators in Georgia and serves as a guide to
ethical conduct. The
Professional Standards Commission has adopted standards that represent the conduct generally accepted by the
education profession. The code protects the health, safety and general welfare of students and educators, ensures
the citizens of Georgia a degree of accountability within the education profession, and defines unethical conduct
justifying disciplinary sanction.
Definitions
“Certificate” refers to any teaching, service, or leadership certificate, license, or permit issued by authority of the
Professional Standards Commission.
“Educator” is a teacher, school or school system administrator, or other education personnel who holds a
certificate issued by the Professional
Standards Commission and persons who have applied for but have not yet received a certificate. For the purposes
of the Code of Ethics for
Educators, “educator” also refers to paraprofessionals, aides, and substitute teachers.
“Student” is any individual enrolled in the state’s public or private schools from preschool through grade 12 or any
individual between and including the ages of 3 and 17.
“Complaint” is any written and signed statement from a local board, the state board, or one or more individual
residents of this state filed with the
Professional Standards Commission alleging that an educator has breached one or more of the standards in the
Code of Ethics for Educators. A “complaint” will be deemed a request to investigate.
“Revocation” is the invalidation of any certificate held by the educator.
“Denial” is the refusal to grant initial certification to an applicant for a certificate.
“Suspension” is the temporary invalidation of any certificate for a period of time specified by the Professional
Standards Commission.
“Reprimand” admonishes the certificate holder for his or her conduct. The reprimand cautions that further unethical
conduct will lead to a more severe action.
“Warning” warns the certificate holder that his or her conduct is unethical. The warning cautions that further
unethical conduct will lead to a more severe action.
“Monitoring“ is the quarterly appraisal of the educator’s conduct by the Professional Standards Commission through
contact with the educator and his or her employer. As a condition of monitoring, an educator may be required to
submit a criminal background check (GCIC). The
Commission specifies the length of the monitoring period.
STANDARDS
Standard 1: Legal Compliance - An educator shall abide by federal, state, and local laws and statutes. Unethical
conduct includes but is not limited to the Commission or conviction of a felony or of any crime involving moral
turpitude; of any other criminal offense involving the manufacture, distribution, trafficking, sale, or possession of a
controlled substance or marijuana as provided for in Chapter 13 of Title 16; or of any other sexual offense as
provided for in Code Section 16-6-1 through 16-6-17, 16-6-20, 16-6-22.2, or 16-12-100; or any other laws applicable to
the profession. As used herein, conviction includes a finding or verdict of guilty, or a plea of nolo contendere,
regardless of whether an appeal of the conviction has been sought; a situation where first offender treatment
without adjudication of guilt pursuant to the charge was granted; and a situation where an adjudication of guilt or
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Teacher Education ATE Application Package Revised: November 2016 LJ
sentence was otherwise withheld or not entered on the charge or the charge was otherwise disposed of in a similar
manner in any jurisdiction.
Standard 2: Conduct with Students - An educator shall always maintain a professional relationship with all students,
both in and outside the classroom. Unethical conduct includes but is not limited to: 1. committing any act of child
abuse, including physical and verbal abuse; 2. committing any act of cruelty to children or any act of child
endangerment; 3. committing any sexual act with a student or soliciting such from a student; 4. engaging in or
permitting harassment of or misconduct toward a student that would violate a state or federal law; 5. soliciting,
encouraging, or consummating an inappropriate written, verbal, electronic, or physical relationship with a student;
6. furnishing tobacco, alcohol, or illegal/unauthorized drugs to any student; or 7. failing to prevent the use of
alcohol or illegal or unauthorized drugs by students who are under the educator’s supervision (including but not
limited to at the educator’s residence or any other private setting). (c)
Standard 3: Alcohol or Drugs - An educator shall refrain from the use of alcohol or illegal or unauthorized drugs
during the course of professional practice. Unethical conduct includes but is not limited to: 1. being on school or
Local Unit of Administration (LUA)/school district premises or at a school or a LUA/school district-related activity
while under the influence of, possessing, using, or consuming illegal or unauthorized drugs; and 2. being on school
or LUA/school district premises or at a school-related activity involving students while under the influence of,
possessing, or consuming alcohol. A school-related activity includes, but is not limited to, any activity sponsored by
the school or school system (booster clubs, parent-teacher organizations, or any activity designed to enhance the
school curriculum i.e. Foreign Language trips, etc). 505-6-.01 Page 3 (d)
Standard 4: Honesty - An educator shall exemplify honesty and integrity in the course of professional practice.
Unethical conduct includes but is not limited to, falsifying, misrepresenting or omitting: 1. professional qualifications,
criminal history, college or staff development credit and/or degrees, academic award, and employment history; 2.
information submitted to federal, state, local school districts and other governmental agencies; 3. information
regarding the evaluation of students and/or personnel; 4. reasons for absences or leaves; 5. information submitted
in the course of an official inquiry/investigation; and 6. information submitted in the course of professional practice.
Standard 5: Public Funds and Property - An educator entrusted with public funds and property shall honor that trust
with a high level of honesty, accuracy, and responsibility. Unethical conduct includes but is not limited to: 1.
misusing public or school-related funds; 2. failing to account for funds collected from students or parents; 3.
submitting fraudulent requests or documentation for reimbursement of expenses or for pay (including fraudulent or
purchased degrees, documents, or coursework); 4. co-mingling public or school-related funds with personal funds
or checking accounts; and 5. using school or school district property without the approval of the local board of
education/governing board or authorized designee.
Standard 6: Remunerative Conduct - An educator shall maintain integrity with students, colleagues, parents,
patrons, or businesses when accepting gifts, gratuities, favors, and additional compensation. Unethical conduct
includes but is not limited to: 1. soliciting students or parents of students, or school and/or LUA/school district
personnel, to purchase equipment, supplies, or services from the educator or to participate in activities that
financially benefit the educator unless approved by the local board of education/governing board or authorized
designee; 2. accepting gifts from vendors or potential vendors for personal use or gain where there may be the
appearance of a conflict of interest; 3. tutoring students assigned to the educator for remuneration unless
approved by the local board of education/governing board or authorized designee; and 4. coaching, instructing,
promoting athletic camps, summer leagues, etc. that involves students in an educator’s school system and from
whom the educator receives remuneration unless approved by the local board of education/governing board or
authorized designee. These types of activities must be in compliance with all rules and regulations of the Georgia
High School Association. 505-6-.01 Page 4 (g)
Standard 7: Confidential Information - An educator shall comply with state and federal laws and state school board
policies relating to the confidentiality of student and personnel records, standardized test material and other
information. Unethical conduct includes but is not limited to: 1. sharing of confidential information concerning
student academic and disciplinary records, health and medical information, family status and/or income, and
assessment/testing results unless disclosure is required or permitted by law; 2. sharing of confidential information
restricted by state or federal law; 3. violation of confidentiality agreements related to standardized testing including
copying or teaching identified test items, publishing or distributing test items or answers, discussing test items,
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Teacher Education ATE Application Package Revised: November 2016 LJ
evised: November 2016 LJ
violating local school system or state directions for the use of tests or test items, etc.; and 4. violation of other
confidentiality agreements required by state or local policy. (h)
Standard 8: Abandonment of Contract - An educator shall fulfill all of the terms and obligations detailed in the
contract with the local board of education or education agency for the duration of the contract. Unethical
conduct includes but is not limited to: 1. abandoning the contract for professional services without prior release
from the contract by the employer, and 2. willfully refusing to perform the services required by a contract. (i)
Standard 9: Required Reports - An educator shall file reports of a breach of one or more of the standards in the
Code of Ethics for Educators, child abuse (O.C.G.A. §19-7-5), or any other required report. Unethical conduct
includes but is not limited to: 1. failure to report all requested information on documents required by the Commission
when applying for or renewing any certificate with the Commission; 2. failure to make a required report of a
violation of one or more standards of the Code of Ethics for educators of which they have personal knowledge as
soon as possible but no later than ninety (90) days from the date the educator became aware of an alleged
breach unless the law or local procedures require reporting sooner; and 3. failure to make a required report of any
violation of state or federal law soon as possible but no later than ninety (90) days from the date the educator
became aware of an alleged breach unless the law or local procedures require reporting sooner. These reports
include but are not limited to: murder, voluntary manslaughter, aggravated assault, aggravated battery,
kidnapping, any sexual offense, any sexual exploitation of a minor, any offense involving a controlled substance
and any abuse of a child if an educator has reasonable cause to believe that a child has been abused.
Standard 10: Professional Conduct - An educator shall demonstrate conduct that follows generally recognized
professional standards and preserves the dignity and integrity of the education profession. Unethical conduct
includes but is not limited to any conduct that impairs and/or diminishes the certificate holder’s ability to function
professionally in his or her employment position, or behavior or conduct that is detrimental to the health, welfare,
discipline, or morals of students.
Standard 11: Testing An educator shall administer state-mandated assessments fairly and ethically. Unethical
conduct includes but is not limited to: 505-6-.01 Page 5 1. committing any act that breaches Test Security; and 2.
compromising the integrity of the assessment. (4) Reporting (a) Educators are required to report a breach of one or
more of the Standards in the Code of Ethics for Educators as soon as possible but no later than ninety (90) days from
the date the educator became aware of an alleged breach unless the law or local procedures require reporting
sooner. Educators should be aware of legal requirements and local policies and procedures for reporting unethical
conduct. Complaints filed with the Georgia Professional Standards Commission must be in writing and must be
signed by the complainant (parent, educator, or other LUA/school district employee, etc.). (b) The Commission
notifies local and state officials of all disciplinary actions. In addition, suspensions and revocations are reported to
national officials, including the NASDTEC Clearinghouse. (5) Disciplinary Action (a) The Georgia Professional
Standards Commission is authorized to suspend, revoke, or deny certificates, to issue a reprimand or warning, or to
monitor the educator’s conduct and performance after an investigation is held and notice and opportunity for a
hearing are provided to the certificate holder. Any of the following grounds shall be considered cause for
disciplinary action against the holder of a certificate: 1. unethical conduct as outlined in The Code of Ethics for
Educators, Standards 1-11 (GaPSC Rule 505-6-.01); 2. disciplinary action against a certificate in another state on
grounds consistent with those specified in the Code of Ethics for Educators, Standards 1-11 (GaPSC Rule 505-6-.01);
3. order from a court of competent jurisdiction or a request from the Department of Human Resources that the
certificate should be suspended or the application for certification should be denied for non-payment of child
support (O.C.G.A. §19-6-28.1 and §19-11-9.3); 4. notification from the Georgia Higher Education Assistance
Corporation that the educator is in default and not in satisfactory repayment status on a student loan guaranteed
by the Georgia Higher Education Assistance Corporation (O.C.G.A. §20-3-295); 5. suspension or revocation of any
professional license or certificate; 6. violation of any other laws and rules applicable to the profession; and 7. any
other good and sufficient cause that renders an educator unfit for employment as an educator. (b) An individual
whose certificate has been revoked, denied, or suspended may not serve as a volunteer or be employed as an
educator, paraprofessional, aide, substitute teacher or in any other position during the period of his or her
revocation, suspension or denial for a violation of The Code of Ethics. The superintendent and the educator
designated by the superintendent/Local Board of Education shall be responsible for assuring that an individual
whose certificate has been revoked, denied, or 505-6-.01 Page 6 suspended is not employed or serving in any
capacity in their district. Both the superintendent and the superintendent’s designee must hold GaPSC certification.
Should the superintendent’s certificate be revoked, suspended, or denied, the Board of Education shall be
responsible for assuring that the superintendent whose certificate has been revoked, suspended, or denied is not
employed or serving in any capacity in their district. Authority O.C.G.A. § 20-2-200; 20-2-981 through 20-2-984.5A
I have read and understand the Code of Ethics for Educators.
Teacher Education ATE Application Package R
Page11
Signature: _______________________________________ Date: ______________
Letter of Recommendation Form
Educator Preparation Program
Applicant:
Date:
SUMMARY EVALUATION
Unacceptable
Below Average
Acceptable
Average
Targeted
Above
Average
Top
10%
Inadequate
Opportunity
To Observe
Research aptitude
Intellectual ability
Ability to work with others
Creativity and
imagination
Maturity
Self-confidence
Communication skills-oral
Communication skills-
written
Analytic ability
Motivation
Potential in career field
Comment Box:
Signature: ________________________________ Date: .
Teacher Education ATE Application Package Revised: November 2016 LJ
Page12
Letter of Recommendation Form
Educator Preparation Program
Applicant:
Date:
SUMMARY EVALUATION
Unacceptable
Below Average
Accepta
ble
Average
Targeted
Above
Average
Top
10%
Inadequate
Opportunity
To Observe
Research aptitude
Intellectual ability
Ability to work with others
Creativity and
imagination
Maturity
Self-confidence
Communication skills-oral
Communication skills-
written
Analytic ability
Motivation
Potential in career field
Comment Box:
Signature: _____________________________________ Date:___________________
Teacher Education ATE Application Package Revised: November 2016 LJ
Page13
Essay Analysis and Critique Rubric
Educator Preparation Program
Two-page minimum
Name: ___________________________________________________________________ RAM ID: ____________________________
Essay Topic: How will I use my content knowledge, technological skills, and cultural awareness to influence and
transform the students that I work with while maintaining Ethical Standards when I become a Educator?
Applicant’s Checklist
12 point size
Concluding paragraph
Times New Roman font
Minimum 3-paragragh body
Typed, double spaced
Introductory paragraph
Scoring Key
Appraisal
Remarks
I.
Content
3 = Well organized and developed content, good use and interpretation of
professional code of ethics, good focus of how writer wants to impact students as
an educator, understands philosophy of education concepts. Demonstrates
awareness of Cultural impacts on Learning and Teaching.
2 = Some organization to content, little interpretation of professional code of ethics,
questionable focus on why writer wants to become educator, questionable
understanding of philosophy of education concept. Little understanding of the
Impact of Cultural systems on Learning and Teaching.
1 = Little organization, little interpretation of professional code of ethics, little focus
on why writer wants to become educator, no understanding of philosophy of
education concepts. No Understanding of Cultural impacts on Learning and
Teaching.
II.
Style
3 = Fluid, easy to read, excellent use of word, descriptive, concise follows assigned
task.
2 = Easy to read but lacking in descriptive quality, some rambling, some misuse of
words, drifts from assigned task.
1 = difficult to follow, extensive rambling, little description, directions not followed.
III.
Mechanics
3 = Targeted: Excellent command of grammar & mechanics; few, if any
Errors.
2 = Acceptable : Good command of grammar & mechanics; some errors
but does not impede comprehension of content
1 = Unacceptable: Poor command of grammar & mechanics;
numerous errors
ADD Sections I thru III
MULTIPLY score x 11
(Minimal Passing Score = 77) Total Evaluation Score
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Teacher Education ATE Application Package Revised: November 2016 LJ
______________________________________ __________________________
Educator Preparation Program
Professional Dispositions Statement
Candidates in the Educator Preparation Program at Albany State University are expected to
demonstrate professional dispositions at the acceptable level. These dispositions will be evaluated by
university professors during classes and university supervisors/cooperating stakeholders during field and
clinical experiences. Failure to do so may result in dismissal from the course, field/clinical experience.
Continued failure to demonstrate professional dispositions may result in dismissal from the Education
Program.
The candidate demonstrates an understanding of the curriculum, subject content, and
pedagogical knowledge for the discipline.
The candidate plans appropriately for class, field/clinical experiences and professional
development opportunities.
The candidate models research based clinical/instructional strategies relevant to the content
area and self-engages in active learning that promotes development of key skills.
The candidate engages in activities and conversations that show an appreciation for individual
learning differences.
The candidate uses reflection, constructive criticism and self-assessment to transform current skills
and dispositions for self and others.
The candidate systematically gathers, analyzes, and uses relevant data to measure self-
progress, to inform clinical/instructional participation, and to engage in relevant conversations
with educational leaders about academic success.
The candidate displays dispositions that contribute to a safe, orderly environment that is
conducive to learning and encourages respect for all.
The candidate contributes to the academic environment in a manner that facilitates teaching
and learning at high levels.
The candidate demonstrates a commitment to professional ethics and dispositions, including
dress, attendance, honesty, confidentiality and criminal offenses.
The candidate communicates effectively with University faculty/staff, other candidates, P-12
students, parents or guardians, district and school personnel, and other stakeholders in ways that
enhance learning.
My signature below indicates that I have read and understand the disposition policy and I agree
to abide by the standards stated while enrolled in the Educator Preparation Program at Albany
State University.
Candidate Signature Date
Teacher Education ATE Application Package Revised: November 2016 LJ
Page15
1.
7.
5.
6.
GaPSC Pre-Service Certificate Application
Please Use Black Ink or Type Revised April 2015
This form must be submitted by an educator preparation provider. Candidates should not submit this form directly to the GaPSC.
1. Please use ALL CAPS to print your LEGAL NAME.
Last Name
First Name Middle Name
Social Security Number Date of Birth (MM/DD/YY) Telephone Number
-
-
/
/
-
-
Mailing Address
City State Zip Code
-
Gender (check one) Ethnicity (check one)
Male Female Are you Hispanic or Latino of any race? Yes No
Race (check all that apply)
Asian
American Indian or Alaska
Black or African
Native Hawaiian or Pacific
White
Native
American
Islander
2. Personal Affirmation: The applicant should enter a truthful "Yes" or "No" response to each of the following questions.
All questions must have a response in order for the application process to continue. "YES" responses automatically
open an investigation and require an attached explanation along with any additional supporting documentation.
DO
NOT include matters that the GaPSC has investigated or is currently investigating.
Y N
Consent:
Y N
Y N
Y N
Have you ever had an adverse action (i.e. warning, reprimand, suspension, revocation, denial, voluntary
surrender, disbarment) taken against a professional certificate, license or permit issued by an agency OTHER
THAN the Georgia Professional Standards Commission?
Y N
2. Are you currently the subject of an investigation involving a violation of a profession’s laws, rules, standards or
Code of Ethics by an agency OTHER THAN the Georgia Professional Standards Commission?
Y N
3. Have you ever received a less than honorable discharge from any branch of the armed services? (If “yes”, provide
a copy of form DD214.)
Y N
4. While under investigation, have you ever
terminated, non-renewed or otherwise)?
left an employment position (retired, resigned, been dismissed,
Are you currently the subject of an investigation involving sexual misconduct or physical harm to a child?
Are you the subject of a pending investigation involving a criminal act?
For any felony or any crime involving moral turpitude, have you ever:
Pled guilty;
♦ Entered a plea of nolo contendere;
♦ Been found guilty;
Pled guilty to a lesser offense;
♦ Participated in a pre-trial diversion program;
Been granted first offender treatment without
adjudication of guilt;
♦ Been found not guilty by reason of insanity; or
Been placed under a court order whereby an
adjudication or sentence was withheld?
Y N
8. Have you ever been convicted, or pled to a lesser offense for any sexual offense?
Y N
9. Have you been convicted of a drug offense (felony or misdemeanor)?
I hereby authorize the Georgia Professional Standards Commission to receive any criminal history record
information pertaining to me which may be in the files of any state or local criminal justice agency in Georgia, and to
perform periodic criminal history background checks for the duration of my certification in the state of Georgia.
Signature: ______________________________________________________ Date: ______________________________
NOTE: This application must be received by the GaPSC within 90 days of the date of signature.
INSTRUCTIONS FOR COMPLETING VERIFICATION OF LAWFUL PRESENCE AFFIDAVIT
In order to obtain a certificate/license from the Georgia Professional Standards Commission (GaPSC), Georgia
law requires every applicant to complete an affidavit (sworn written statement) before a Notary Public that
establishes that the applicant is lawfully present in the United States of America. This affidavit is a material part of
your GaPSC certification/licensure application and must be completed truthfully. Your application may be denied
or your certificate may be revoked by the GaPSC if it is determined that you have made a material misstatement
of fact in connection with your application. Please follow the instructions listed below.
You must submit the following with your Pre-Service Application and GCIC Consent Form:
1. Notarized Affidavit (page 3 of this document)
2. A copy of an acceptable ID (see below)
1. Select the ONE option on the affidavit that applies to you:
Option 1 is to be initialed/selected by you if you are a United States citizen; or
Option 2 is to be initialed/selected by you if you are a legal permanent resident of the United States: you
are not a U.S. citizen but you have a green card; or
Option 3 is to be initialed/selected by you if you are a qualified alien or non-immigrant (but not a U.S.
citizen or a legal permanent resident).
If you selected Option 2 or 3, please provide the number (whether or not it is called an alien number”)
issued by the Department of Homeland Security or other federal immigration agency in the blank space
following this statement: “My alien number issued by the Department of Homeland Security or other federal
immigration agency is:”
2. Select an acceptable ID based on your selection in Step 1.
Acceptable IDs for Option 1 (U.S. citizen) are:
o An unexpired driver’s license issued by a U.S. state, D.C., or certain U.S. territories
o An unexpired United States passport or passport card
o An unexpired United States military identification card
o Any document listed here:
http://www.gapsc.com/certification/downloads/SecureVerifiableDocuments.pdf
The only acceptable ID for Option 2 (legal permanent resident) is a copy of the front and back of your
unexpired United States Permanent Resident Card.
Acceptable IDs for Option 3 (qualified alien or non-immigrant) are:
o An unexpired work authorization card
o I-94 documentation reflecting the I-94 number and expiration date AND a valid foreign passport
o A valid Certificate of Eligibility reflecting your SEVIS number AND a valid foreign passport
Fill in the type of ID (e.g. Georgia driver’s license, U.S. passport, etc.) that you are using on the affidavit on
the line after “The secure and verifiable document provided with this affidavit can best be classified as:”
3. Print out the affidavit (page 4 of this document).
4. Find a local Notary Public. Check the yellow pages, the internet, or with a local business such as a bank.
5. Bring your affidavit and the ID you selected (from the list in Step 2) to appear before the Notary Public.
6. Show the Notary Public your ID and state under oath in the presence of the Notary Public that you are
who you say you are and that you are in the United States lawfully. Then sign your name.
7. Make certain that the Notary Public signs and dates the affidavit and lists when their notary
commission expires.
8. Make a copy of the affidavit and the ID that you presented to the Notary Public for your own records.
9. Submit the following with your Pre-Service Application and GCIC Consent Form:
A copy of the signed and notarized affidavit; and
A copy of the ID you presented to the Notary Public.
____________________________________
____________________________________
_________________________
O.C.G.A. § 50-36-1(e)(2) Affidavit
By executing this affidavit under oath, as an applicant for a Georgia Educator Certificate/License, as
referenced in O.C.G.A. § 50-36-1, from the Georgia Professional Standards Commission, the undersigned
applicant verifies one of the following with respect to application for a public benefit:
1) _________ I am a United States citizen.
2) _________ I am a legal permanent resident of the United States.
3) _________ I am a qualified alien or non-immigrant under the Federal Immigration and Nationality Act
with an alien number issued by the Department of Homeland Security or other federal
immigration agency.
My alien number issued by the Department of Homeland Security or other federal
immigration agency is: ____________________.
The undersigned applicant also hereby verifies that he or she is 18 years of age or older and has provided at
least one secure and verifiable document, as required by O.C.G.A. § 50-36-1(e)(1), with this affidavit.
The secure and verifiable document provided with this affidavit can best be classified as:
_______________________________________________________________________.
In making the above representation under oath, I understand that any person who knowingly and willfully
makes a false, fictitious, or fraudulent statement or representation in an affidavit shall be guilty of a violation
of O.C.G.A. § 16-10-20, and face criminal penalties as allowed by such criminal statute.
Executed in ___________________ (city), __________________(state).
Signature of Applicant
Printed Name of Applicant
SUBSCRIBED AND SWORN
BEFORE ME ON THIS THE
___ DAY OF ___________, 20____
NOTARY PUBLIC
My Commission Expires:
Albany State University Police Department/College of Education
Consent Form
Semester/Year: _________________ Home Campus: ASU Cairo Waycross (Circle One)
Purpose of Criminal Background Check:
Program: ______________________________ Ex. Early Childhood _____ Admission to Teacher Education
Concentration(s): ________________________ (Middle Grades & SPED only) _____ Field Experiences
_____ Practicum I, II, or III
Education Classes: ____________________________________________ _____ Clinical Experiences/Student Teaching
Leadership Classes: ___________________________________________ _____ Leadership Residency
Counseling Classes: ___________________________________________ _____ Counseling Practicum
I,______________________ hearby authorize Albany State University to receive any Georgia crimininal record
pertaining to me which may be in the files of any state or local criminal justice agency in Georgia.
Please type or print the following information: (ALL FIELDS MUST BE COMPLETED).
Last Name Middle Name First Name Maiden Name
Address City State Zip Code
Phone # Sex/Race Date of Birth Social Security
For Security Department Use Only
Arrest record on file? (If record, see attached) _____________________________________________
Record of any convictions? (If record, see attached)_____________________________________________
Signature, ASU Police Representative ______________________________ Date _____________________
_______________________________________________________________
Albany State University Police Department/College of Education
AUTHORIZATION FOR RELEASE OF INFORMATION
Please print clearly all requested information.
First Name___________________ Middle Name_______________ Last Name__________________________
Date of Birth_________________ SSN______________________ Ram ID_____________________________
Address___________________________________________________________________________________
Major_________________________________ Classification ________________________________________
City______________________________________ State_________ Zip Code___________________________
Home Telephone Number__________________________ Cell Number _______________________________
I hereby authorize your company, Albany State University, or any agent of said company, to contact any of my
previous employers or contact schools, companies, credit bureaus, corporations, law enforcement agencies,
persons, and educational institutions to supply any information concerning my background.
I hereby also give my permission for the release of all appropriate background information permissible by
governing laws to the College of Education and Local Education Agencies (LEAs) to which I may be assigned
to conduct field and/or clinical experiences.
This authorization is valid 90/180 days from the date of signature. I fully understand the terms of this release
and attest that the information I have provided is accurate, true and correct.
Executed this ______________day of______________________________, 20______
(Date) (Month) (Year)
(City) (State)
Candidate (Student) Signature ____________________________________
Notary Public Signature __________________________________________
My Commission Expires: _________________________________________
Albany State University agrees that neither NCIC, GCIC its employees nor any other agency or employees of the state
of Georgia shall be responsible for the accuracy of information or have any liability for defamation, invasion of privacy,
negligence or any other claim in connection with any dissemination of information pursuant to this record check.