Fillable Form LA Revised August 2021: LICENSURE INSTRUCTIONS Mississippi (Mississippi)

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Form LA Revised August 2021: LICENSURE INSTRUCTIONS Mississippi (Mississippi)

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Office of Teaching and Leading
Division of Educator Licensure
Form LA Revised August 2021
LICENSURE INSTRUCTIONS
Mississippi Department of Education
Office of Educator Licensure
(601) 359-3483
Please read directions carefully:
1. All educators must apply for licensure requests online through the Educator
Licensure Management System (ELMS). ELMS is accessible through the Mississippi
Department of Education (MDE) website at https://www.mdek12.org . Your ELMS account will
provide you with your Educator ID number and allow you to upload supporting documents for your
application. When applying online, remember that supporting documents from the Licensure
Checklist must be uploaded with your application to complete the licensure request.
If completing a paper application, complete and upload the Licensure Application (pp. 2-3) with
all other required documents as a complete packet to the correspondence page of your ELMS
account. A complete packet includes an Application, plus all documents listed under your licensure
category from the Licensure checklist. Applications that are uploaded without supporting documents
will be considered incomplete, and the educator will be sent a “requirements” letter via email,
stating which documents are needed to further process the licensure request.
The Licensure Application, Licensure Checklist and all referenced forms in the License Checklist can
be obtained by visiting https://www.mdek12.org/OEL/Forms unless otherwise specified.
2. All transcripts from all institutions must be submitted directly by the university or college
electronically in a secure electronic format via National Student Clearinghouse, Parchment, or any
other transcript exchange service provider. Electronic transcripts may be transmitted by the
university or college to transcript@mdek12.org. This email address is used for the purpose of
submitting official transcripts only. Transcripts sent to this email address or uploaded to the ELMS
correspondence page by the applicant are not considered official for licensure purposes.
3. All Praxis test takers who test in the state of Mississippi test score results are automatically
reported to the MDE. To ensure successful retrieval of scores automatically reported to the MDE,
please be sure to include your full and correct social security number. If you test out of state, please
designate the MDE as a score recipient during the test registration process.
For additional information regarding educator licensure, please visit the Mississippi
Department of Education, Office of Educator Licensure webpage:
https://www.mdek12.org/OEL
Form LA, revised August 2021, page 2
LICENSURE APPLICATION
(Must be LEGIBLY completed and submitted with all licensure requests)
APPLICANT INFORMATION
Social Security Number: _________________ Email Address: ___________________
Legal Name: _______________ ____________ ____________ ________________
Last First Middle Maiden
Address: __________________________________________ ________________
Street/P.O. Box Apt#
____________________________________ _________ ___________
City State Zip
Phone Number: ____________________ Birthdate: _____________ Gender: _____
Ethnicity: (Ethnicity information is used for statistical purposes and to provide information required by
the U.S. Department of Education in accordance with applicable federal regulations. Your cooperation in
providing this information is appreciated.)
☐American Indian ☐Alaskan Native ☐Asian ☐Black: non-Hispanic
☐White: non-Hispanic ☐Hispanic ☐Pacific Islander ☐Other
Military Experience (Check, if applicable)
☐Army ☐USAF ☐Navy ☐USMC ☐Reserve ☐MSNG ☐Coast Guard
LICENSURE REQUEST
Class of license for which you are applying:
☐A (Bachelor) ☐AA (Master) ☐AAA (Specialist) ☐AAAA (Doctorate)
☐Check here if you are applying for a class upgrade at this time
Type of License (see Licensure Checklist for descriptive information)
☐
Approved Program/Teacher Education Route Subject Area(s):_________________________
☐
Alternate Route Subject Area(s):_________________________
☐
Supplemental Endorsement Subject Area(s):_________________________
☐
Administrator License (select license level)
☐
Non-Practicing
☐
Entry
☐
Career
☐
School Business Administrator (select)
☐
Three Year
☐
Five Year
☐
District Superintendent License (select)
☐
Three Year
☐
Five Year
☐
Duplicate
☐
Reciprocity
☐
Renewal/Reinstatement
☐
JROTC
Form LA, revised August 2021, page 3
This Section Must Be Completed by Applicants for Licensure in the Areas of Psychometry and/or
School Psychologist Only:
The undersigned applicant for licensure in the area(s) of psychometrist and/or school psychologist hereby
affirms that the aforementioned titles shall only be used when they are employed by or under contract with a
school district and practicing in school or educational settings" (emphasis added). Explicitly, Mississippi Code
Annotated § 73-31-27, paragraph two (2), states, "Individuals certified by the Mississippi State Department of
Education may use appropriate titles such as "school psychologist," "certified school psychologist," "educational
psychologist" or "psychometrist" only when they are employed by or under contract with a school district and
practicing in school or educational settings" (emphasis added). Furthermore, your signature serves as
confirmation of your understanding that your scope of practice as a psychometrist and/or school psychologist is
limited to these settings when holding only a license granted and issued by the Mississippi Department of
Education, which does not include work in a private practice type setting, by this statute.
Signature of Applicant: _____________________________________________________
CHARACTER DETERMINATION
Check “yes” or “no” to the left of each question
☐Yes ☐No Are you currently addicted to or dependent on alcohol?
☐Yes ☐No Are you currently addicted to or dependent on habit forming drugs?
☐Yes ☐No Are you a habitual user of narcotics, barbiturates, amphetamines, hallucinogens, or other
. drugs having similar effects?
☐Yes ☐No Have you been convicted of, or pled guilty to, a felony as defined by federal or state law?*
. (For the purpose of this question, a “guilty plea” includes a please of guilty, entry of a plea of .
nolo contendere, or entry of any order granting pretrial or judicial diversion.)
☐Yes ☐No Have you been convicted of, or pled guilty to, a sex offense as defined by federal or state law?* .
(For the purpose of this question, a “guilty plea” includes a please of guilty, entry of a plea of .
nolo contendere, or entry of any order granting pretrial or judicial diversion.)
☐Yes ☐No Are you currently on probation or post-release supervision for a felony or sex offense as .
defined by federal or state law?*
☐Yes ☐No Have you had a certificate/license denied, suspended, and/or revoked by MS or another state
. or have you voluntarily surrendered a certificate/license?
If you answered “yes” to any of the above provide, on a separate sheet of paper, the
specifics or an explanation for the response. If you elect not to provide specifics or if such
an explanation is insufficient, a confidential investigation will be initiated.
*If you answered “yes” submit official copies of court records including disposition of case.
ACKNOWLEDGEMENT
I acknowledge that securing or attempting to secure a license by fraud or deceit will result in denial of this
application or suspension of the license.
Signature: _________________________________ Date: ____________________
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Form LA Revised August 2021: LICENSURE INSTRUCTIONS Mississippi (Mississippi)

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Completed 8 February 2022

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