FORM
6
a
Teacher Licensure and Accreditation - Kansas State Department of Education
APPLICATION FOR KANSAS RESTRICTED
CAREER AND TECHNICAL EDUCATION CERTIFICATE
1 ww w.ksde.org
REV: 08-20-2018
KSDE INTERNAL USE ONLY
LEGAL M & E + SIGNATURE FEE SS#
SEND BACK RAP EXPIRATION FP IN VERIFIED BY
SECTION A: TO BE FILLED OUT BY APPLICANT
Social Security Number
________________________________________
Birthdate (MM/DD/YYYY)
________________________________________
Gender:
Male Female
LEGAL NAME: First Name
________________________________________
Middle Name
________________________________________
Last Name
________________________________________
All prior names (Maiden, alias, previous married, etc.)
______________________________________________________________________________________________________________________________
Mailing Address
______________________________________________________________________________________________________________________________
City
________________________________________
State
________________________________________
Zip
________________________________________
Phone
________________________________________
Alt Phone
________________________________________
Email Address
________________________________________
Ethnicity (mark only if applicable)
Hispanic/Latino
Race (mark one or more as applicable)
American Indian or Alaska Native
Black or African American
White
Asian
Native Hawaiian or Other Pacic Islander
Choose not to designate
Military Service: Have you honorably Served in any brand of the US Armed Forces, including the National Guard and Reserves?
NO YES If Yes, please enter total years below in a and b.
a. Total years of active duty service in any branch of the US Armed Forces (if none enter “0”): __________________
b. Total years of national guard/reserve service (if none enter “0”): __________________
Please read the following questions very carefully. Failure to accurately answer these questions or submit appropriate
documents will delay the issuance of your license. Unless expunged, you are required to disclose both adult and juvenile
oenses.
a. Have you EVER been convicted of a felony?
NO YES
If yes, please attach a certied copy of the following documents:
• Charging document
• Journal entry of conviction
b. Have you EVER been convicted of ANY crime involving
theft, drugs, or a child?
NO YES
If yes, please attach a certied copy of the following documents:
• Charging document
• Journal entry of conviction
c. Have you EVER entered into a diversion agreement
or otherwise had a prosecution diverted after being
charged with any felony or any crime involving theft,
drugs, or a child?
NO YES
If yes, please attach a certied copy of the following documents:
• Charging document
• Diversion agreement
• Journal entry closing that case
d. Are criminal charges pending against you in any state
involving any felony or any crime involving theft, drugs,
or a child?
NO YES
If yes, please attach a certied copy of the
• Charging document
e. Have you had a teacher’s or school administrator’s
certicate or license denied, suspended, revoked or been
the subject of other disciplinary action in any state?
NO YES
If yes, please indicate the action taken:
Denied
Suspended
Revoked
Which State(s):________________________________________
Please attach a copy of the documents regarding the ocial action
taken.