Fillable Form La 2020.04.06

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Form La 2020.04.06

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Office of Teaching and Leading
Division of Educator Licensure
Form LA Revised March 2020
LICENSURE INSTRUCTIONS
Mississippi Department of Education
Office of Educator Licensure
P. O. Box 771
Jackson, MS 39205-0771
(601) 359-3483
Please read directions carefully:
1. All educators are encouraged to 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, that have been scanned as a PDF, for your application (photocopies are not accepted).
When applying online, remember that supporting documents from the Licensure Checklist must
still be mailed to the address above to complete licensure request.
If submitting a paper application, complete and return the Licensure Application (pp. 2-3) with
all other required documents as a single, complete packet to the address above, or scanned as a
PDF and uploaded to your ELMS account. A complete packed includes an Application, plus all
documents listed under your licensure category from the Licensure checklist. Applications that
arrive without supporting documents will be considered incomplete, and the educator will be mailed
a “requirements” letter, stating which documents are needed to 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 in a sealed envelope(s) bearing the seal or
signature of the registrar. It should be mailed to you and may be stamped “student issued.” Do not
open the sealed envelope. The Office of Educator Licensure also accepts electronic transcripts
through eScripSafe or Clearinghouse Transcript Exchange if the institution at which the degree was
earned or acceptable coursework was taken utilizes the services offered by one of the organizations
noted here. This is the fastest, most secure way to get your transcripts to the Office of Educator
Licensure.
3. All Praxis test takers who test in the state of MS 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. If you do not request your scores be
sent electronically to MDE, you can submit an official paper copy of all pages of your score report to
the Office of Educator Licensure.
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 March 2020, page 2
LICENSURE APPLICATION
(Must be LEGIBLY completed and submitted with all licensure requests)
APPLICANT INFORMATION
Social Security Number: _____ ___ ________ Email Address: ___________________
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)
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):_________________________
☐District Superintendent License (select): ☐Three Year ☐Five Year
☐Administrator License (select level of license) ☐Non-Practicing ☐Entry ☐Career
☐School Business Administrator (select): ☐Three Year ☐Five Year
☐Duplicate ☐Reciprocity ☐Renewal/Reinstatement ☐JROTC
☐COVID-19 Extension (select): ☐Local District Requested License ☐All Other License Types
Name of Local District (Applicable to Local District Option):_______________________________
Form LA, revised March 2020, page 3
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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Completed 20 April 2020

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