MO 500-3120 (03/15)
The Department of Elementary and Secondary Education does not discriminate on the basis of race, color, religion, gender, national origin, age, or disability in its programs
and activities. Inquiries related to Department programs and to the location of services, activities, and facilities that are accessible by persons with disabilities may be directed
to the Jefferson State Office Building, Office of the General Counsel, Coordinator – Civil Rights Compliance (Title VI/Title IX/504/ADA/Age Act), 6
th
Floor, 205 Jefferson Street,
P.O. Box 480, Jefferson City, MO 65102-0480; telephone number 573-526-4757 or TTY 800-735-2966 email civilrights@dese.mo.gov.
MISSOURI DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION
OFFICE OF EDUCATOR QUALITY – EDUCATOR CERTIFICATION
UPDATE PERSONAL AND EDUCATION INFORMATION REQUEST
SOCIAL SECURITY NUMBER
EDUCATOR ID
LAST NAME
FIRST NAME
MIDDLE INITIAL
ALL MAIDEN/FORMER NAMES
GENDER
DATE OF BIRTH
STREET ADDRESS
CITY
STATE
ZIP CODE
PHONE NUMBER (CELL)
PHONE NUMBER (HOME)
.
PHONE NUMBER (WORK)
EMAIL
Please provide your current legal name (Last, First, and Middle Initial).
Please return this cover sheet along with supporting documentation to:
Missouri Department of Elementary and Secondary Education
Educator Certification
PO Box 480
Jefferson City, MO 65102-0480
QUESTIONS: Contact Educator Certification (573) 751-0051
PLEASE CHECK THE BOX FOR THE INFORMATION THAT YOU WISH TO UPDATE AND COMPLETE THE
REQUESTED INFORMATION. MORE THAN ONE REQUEST MAY BE PROCESSED WITH THIS FORM.
I request a name change
FROM
TO
(Please enclose a photocopy of documentation that supports the name change.)
I request a correction of my Social
FROM
TO
(Please enclose a photocopy of Social Security Card.)
I request a correction of my Date of
FROM
TO
(Please enclose a photocopy of documentation that supports the Date of Birth.)
I request an update to my education records. Original
transcripts required. No photocopies.
Need to add degree.
Need to correct attendance dates, GPA, etc.
ORIGINAL SIGNATURE REQUIRED - No faxes or photocopies of this form will be accepted.
LEGAL SIGNATURE OF APPLICANT
DATE
