Revised LaRuth Lofties 2/15/2016
Personal Information (PLEASE TYPE and PRINT FORM)
Name (last, first, middle):
Banner ID: U00
Local Address:
Permanent Address:
Home Phone: Cell Phone: Alternate Phone:
University Email Address:
Program Information
Are you currently admitted to the MAT program? Yes No
Check one:
Art K-12
Elementary K-5
Early Childhood PreK-3
ESL PreK-12
Library Information Specialist
Physical Education K-12
Special Education
SPED Area: Interventionist K-12 Comprehensive K-12 SPED Early Childhood PreK-3
Secondary 6 -12 Specify subject area: ________________________________
Teacher Education
Program Application
Graduate (MAT)
Revised LaRuth Lofties 2/15/2016
Institution Degree Year GPA Minor
Experience Working with Children/Youth
Check all that apply:
Currently teaching
Teacher Aide
Church related teaching
Recent and extended childcare (babysitting, daycare)
Volunteer programs
Tutoring adults or children
Other: ________________________________________________________________
Explain: ______________________________________________________________
Are you currently a full-time teacher? Yes No
If so, please give the name of the school district and the school you are employed with:
Revised LaRuth Lofties 2/15/2016
Test Information
CORE Academic Skills Scores
Reading: _____________
Writing: ______________
Math : ________________
GRE Exam: ____________
Praxis II Content Knowledge
Test Code: _____________
Test Name:
Score: _________________
Please read and sign the following verification of understanding:
I attest that all information given on this application is a true and accurate
account of my current status. I give my permission for the information in this
application to become part of my program records.
Signature: ___________________________________ Date: ___________________
click to sign
click to edit