Fillable Eligibility Form To Add an Additional Field to (Minnesota)

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Eligibility Form To Add an Additional Field to (Minnesota)

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Eligibility-Add 07_2020 Page 1 of 2
Eligibility Form
Licensure via Portfolio Evaluation Application:
To Add an Additional Field to a Tier 3 or Tier 4 License
THIS FORM IS VALID FOR ONE YEAR. *PLEASE SEE INFORMATION ON PAGE 2
Send the following information: (1) this Eligibility form; (2) a copy of your regionally accredited
college transcripts; (3) a written description of your teaching or related experiences; and (4)
your resume to the Minnesota Professional Educator Licensing and Standards Board.
File Folder # ______________
Name: __________________________________________________ Date: _________________________
Address: ___________________________________ City: _________________ State: ____ ZIP: ________
Home Phone: ______________ Alternate Phone: _______________ Email: _________________________
Education
Degree: _______ Major(s):___________________________Institution: _______________________________________
Degree: _______ Major(s):___________________________Institution: _______________________________________
Teaching Experience
Teaching Assignment: ________________School: ______________________Years of Teaching Experience: ________
Teaching Assignment: ________________School: ______________________Years of Teaching Experience: ________
Portfolio Application Submitted for (check all that apply): *Further instructions on page 2
Special Education Core Skills Subject Matter Standards and Content Specific Fields (list below)
Career and Technical Education Core Skills
Field: Field:
Field: Field:
_________________________________________ _______________________
Applicant’s Signature Date
For Office Use Only:
Date Info Verified: _______________ Date Emailed: _________________
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Eligibility-Add 07_2020 Page 2 of 2
Eligibility Form
Licensure via Portfolio Evaluation Application Information
To Add an Additional Field to a Tier 3 or Tier 4 License.
• This form is valid for one year.
• Minnesota teachers holding a professional tier 3 or tier 4 license who want to expand the grade
level of the current license or add an additional field to the current license may use the
licensure via portfolio process as an alternative pathway to a tier 3 or tier 4 license.
• All testing must be completed before license is issued.
• Portfolio review fee is non-refundable.
Form and documentation can be emailed to: portfolio.pelsb@state.mn.us, or mailed to:
Licensure via Portfolio-PELSB
1021 Bandana Blvd E Suite 222
St. Paul, MN 55108
*Content Standard Grids for Educator Licenses via Portfolio
Standards of Effective Practice Grid
A Standards of Effective Practice (pedagogy) portfolio is a requirement for an initial tier 3 license.
Core Skills for Teachers of Career and Technical Education Grid
A Core Skills for Teachers of Career and Technical Education portfolio is required for a tier 3/tier 4
license in the Career and Technology Education fields such as; Communication Technology Careers,
Construction Careers, Manufacturing Careers, Medical Careers, Creative Design Careers, Early
Childhood Careers, Hospitality Service Careers, and Transportation Careers.
Core Skills for Teachers of Special Education Grid
A Core Skills for Teachers of Special Education portfolio is required for a tier 3/tier 4 license in the
Special Education fields such as; Academic and Behavioral Strategist, Blind or Visually Impaired,
Deaf or Hard of Hearing, Oral/Aural Deaf Education, Developmental Adapted Physical Education,
Developmental Disabilities, Early Childhood Special Education, Emotional or Behavioral Disorders,
Learning Disabilities, Physical and Health Disabilities, and Autism Spectrum Disorders.
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Eligibility Form To Add an Additional Field to (Minnesota)

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Completed 17 March 2021

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