Fillable Minnesota Educator Tier 4 License Application (Minnesota)

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Minnesota Educator Tier 4 License Application (Minnesota)

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Application for a Tier 4 Minnesota Educator License: May 2020 Page 1 of 12
Minnesota Educator Tier 4 License Application
Application General Information and Checklist
General Information: A Tier 4 licensure candidate must hold a minimum of a bachelor’s degree, have passed the
MTLE content and pedagogy exams in the licensure field requested, show proficiency in basic skills testing, evidence
completion of a teacher preparation program, and have at least three years of teaching experience in a Minnesota
school. CTE/Career Pathways candidates see requirements on the CTE/Career Pathways application
. The Tier 4 license is
valid for five years and expires on June 30 of the expiration year. A Tier 4 license may be renewed an unlimited number
of times. Renewal requirements include 125 clock hours, including current mandatory requirements. If a candidate holds
a Tier 3 or Tier 4 license, the district must apply for an out-of-field permission rather than a Tier 1 or Tier 2 license to be
able to teach outside their licensure field.
ALL APPLICATIONS MUST INCLUDE THE FOLLOWING TO BE CONSIDERED
Review and check the below list to ensure you have completed the required paperwork and included all required
materials for submission. All applications must include Sections 1, 2, 3, 4, 5, and 6.
Application processing fee in the form of a check or money order made payable to “PELSB.”
For initial/first-time applicants: an initial application and fingerprint card processing fee of $90.25.
For existing license holders: an application fee of $57.00 (fingerprint card is not required).
Fingerprint card completed for initial applications, signed and dated. Be sure NOT to fold or bend the card.
To request a fingerprint card, please email PELSB staff at pelsb@state.mn.us or call 651-539-4200 (option 1)
and include your full name and current mailing address in your message. The subject line of the email should
be “Fingerprint Card Request.” Include the completed fingerprint card with the complete application.
Official transcripts from all regionally accredited colleges or universities attended in an institution’s sealed
envelope. In most instances, earned degrees must be posted on transcripts.
If you are adding a new licensure field to an existing Minnesota license, submit transcripts that have not
been previously submitted and/or that are related to the licensure field requested.
For individuals with preparation completed outside of the United States or its territories, transcripts must be
evaluated by a foreign credential evaluation service. The
National Association of Credential Evaluation
Services (NACES) has a list of approved providers. Please mail the original course-by-course evaluation of
your foreign preparation to PELSB.
Completed application, signed, dated, and including Sections 1-4.
Designated Address: Your designated address may be a residence, PO Box, or place of business. Please note
that the address you designate on this form does not remain private after a license is issued.
Home Address: Your home address remains private if a designated address is supplied. If there is no
designated address, the home address does not remain private after a license is issued.
Section 5A: Conduct Review Statement completed, signed and dated AND, if you answered YES to questions 1,
2, 3, 4, or 6, complete Section 5B. If you answered YES to questions 5, 7, 8, 9, 10, 11, or 12, include the
additional materials requested.
Section 6: Verification of Completion of a State-approved Program
This form must be completed, signed and dated by the certifying officer of the institution where the teacher
preparation program was completed.
Section 7: Verification of Teaching Experience Form
• This form must be completed, signed, and dated by an authorized school official.
PARTIAL OR INCOMPLETE APPLICATIONS WILL BE RETURNED
Application for a Tier 4 Minnesota Educator License: May 2020 Page 2 of 12
Instructions for a Tier 4 Minnesota Educator License Application
It is the applicant’s responsibility to submit the required items in ONE complete packet to PELSB. To ensure the
submission of a complete packet, review and follow the instructions below.
A check or money order payable to “PELSB” must be included. This is a non-refundable processing fee.
• Initial/First Time Minnesota Educator License Application Fee: $90.25 which includes fingerprint card fee.
Request a fingerprint card from PELSB. Include the completed fingerprint card with the complete application.
• Existing Minnesota License Holder Application Fee: $57.00 (does not require a fingerprint card.)
Mailing Address Telephone Number Web Address Email Address
PELSB
1021 Bandana Blvd. East, Suite 222
Saint Paul, MN 55108-5111
651-539-4200 https://mn.gov/pelsb/ pelsb@state.mn.us
Minnesota Statutes 122A.184 Tier 4 License (https://www.revisor.mn.gov/statutes/cite/122A.184)
Important Information
• This application is for general and special education. If you are seeking a Career and Technical Education (CTE)
or Career Pathways license, you will need to complete the CTE or Career Pathways application.
• If this is an initial Minnesota license or you have only held a Community Expert permission, completion of a
fingerprint card and submission of official transcripts is required. You will pay the $90.25 fee. Include the
completed fingerprint card with the complete application.
• If you are adding a new licensure field to or renewing an existing Minnesota license, you do not need to
complete a fingerprint card or send documentation that relates to your existing license. You will ONLY send
documentation that is new since your last application AND pertains to the licensure field you are requesting on
this application.
Section 1: Applicant Information
• Name: Provide your legal name as it appears on your social security card. If you are adding a new licensure field
to an existing Minnesota license AND you have a NAME CHANGE, please attach a Name Change Authorization
form.
• Social Security or Individual Taxpayer Identification Number: Minnesota Statute 270C.72, Subdivision 4 requires
all agencies that issue licenses to collect social security (SSN) or individual taxpayer identification (ITIN) numbers
as part of the application. Your application will be deemed incomplete if not provided.
• Email: It is important to provide an email address that you have access to throughout the year. Important
information will be sent to this email address, including instructions on how to print the e-license.
• Designated Address: Your designated address may be a residence or place of business. Please note that the
address you designate on this form does not remain private after a license is issued.
• Home Address: Your home address remains private if you enter a separate designated address. If there is no
designated address, the home address does not remain private after the license is issued.
• Ethnicity/Race: This section is optional and will not affect the decision of the application.
Section 2: Application Type
• Be sure to include the licensure field you are requesting on this application. If you are unsure of what the name
of the licensure field is, please see the Minnesota Licensure Fields document.
• If you hold an existing Tier 4 Minnesota license and are adding a new licensure field with this application, be
sure to indicate this by checking the statement in this section.
• If you are adding AND renewing an existing Tier 4 Minnesota license with this application, indicate that you are
also renewing by checking the statement in this section. All clock hours must be reported before you apply.
Application for a Tier 4 Minnesota Educator License: May 2020 Page 3 of 12
• If you are applying for a license in the field of School Counselor, School Nurse, School Psychologist, School
Social Worker, or Speech-Language Pathologist, be sure to read all these instructions for additional information
on requirements for your application.
• If you are renewing only, please use the Online License Renewal System
.
Section 3: Educational Background
• All first-time applicants must complete this section.
• If adding a licensure field, only include information since your last license was issued.
• Official transcripts in an institution’s sealed envelope must be included with the rest of the required application
materials for licensure. All mailed materials must be submitted in one complete packet.
• If you hold an existing Minnesota educator license, only submit official transcripts that have not been submitted
previously.
Section 4: Licensure Requirements
• All applicants must complete this section.
• If you hold an educator license in another state, include a copy of the license.
• If you have completed the education requirements in Minnesota for a license in School Counselor, School
Nurse, School Psychologist, School Social Worker, or Speech-Language Pathologist, check Minnesota state-
approved program option. See Section 6 for education requirements.
• If you have completed the education requirements outside of Minnesota for a license in School Counselor,
School Nurse, School Psychologist, School Social Worker, or Speech-Language Pathologist, check the outside of
Minnesota option. See Section 6 for education requirements.
Section 5: Conduct Review
• All applicants are required to complete Section 5A.
• If this is NOT your first application for a Minnesota education license, your answers on the conduct review
statement apply only to the period since your last license was issued.
• If you answered YES to questions 1, 2, 3, 4, or 6; complete Section 5B.
• If you answered YES to questions 5, 7, 8, 9, 10, 11, or 12; include the additional materials requested.
Section 6: Verification of Completion of a State-Approved Licensure Program
• This verification form must be completed by the official certification officer at the recommending college,
university, or institution.
• School Nurse, School Psychologist, School Social Worker, or Speech-Language Pathologist applicants are NOT
required to complete this section. YOU ARE REQUIRED to submit official transcripts from all institutions in an
institution’s sealed envelope.
• School Nurse applicants MUST submit evidence (official transcripts) of completion of a nursing program and
include a copy of your current licensure as a Minnesota registered nurse AND current registration as a Minnesota
public health nurse.
• School Psychologist applicants MUST submit evidence (official transcripts) of completing a preparation program
in school psychology accredited by the National Association of School Psychologists (NASP).
• School Social Worker applicants MUST submit evidence (official transcripts) of completing a program accredited
by the Council on Social Worker Education (CSWE) and you MUST include a copy of your current Minnesota
Board of Social Work license.
• Speech-Language Pathologist applicants MUST submit all official transcripts and provide evidence of a master’s
degree in Speech-Language Pathology from a program accredited by the Council on Academic Affairs of the
American Speech-Language-Hearing Association (ASHA) a valid certificate of clinical competence from ASHA, or a
valid speech-language pathologist license from the Minnesota Department of Health.
• School Counselor applicants that have completed a preparation program for school counseling accredited by the
Council for the Accreditation of Counseling and Related Educational Personnel (CACREP) are not required to
Application for a Tier 4 Minnesota Educator License: May 2020 Page 4 of 12
complete this section. You are still REQUIRED to submit official transcripts from all institutions in a sealed
envelope.
• School Counselor applicants that have completed a preparation program not accredited by CACREP MUST
submit Section 6, as well as submit official transcripts in a sealed envelope.
• If you have submitted this form previously (e.g. for a Tier 3 license), you do not need to submit this section
again. If you are adding a licensure field, this completed form must be submitted for the new licensure field.
Section 7: Verification of Teaching Experience
• For initial Tier 4 applicants: Complete this section if you are providing documentation of three or more years of
teaching experience in Minnesota.
Privacy Statement:
The data you provide on an application for Minnesota education licensure will be used by Minnesota Professional
Educator Licensing and Standards Board to assess your qualifications for licensure. You are not legally required to
provide this data. However, if you fail to provide information, PELSB may be unable to process your license
application. Until licensure is granted, the information you provide on the application is private data, accessible to
only you, PELSB, its staff, and/or staff of the Attorney General’s Office representing PELSB. Your application and all
submitted application materials, except your Social Security number, become public data if licensure is granted,
according to Minn. Stat. § 13.41, Subd. 5
.
Under Minn. Stat. § 270C.72, PELSB is required to provide your Social Security number to the Minnesota
Commissioner of Revenue. This information may be used to deny the issuance and renewal of your license or to
revoke your license if you owe the Minnesota Department of Revenue delinquent taxes, penalties, or interest. PELSB
will provide only your Social Security number to the Department of Revenue. However, under the Federal Exchange
of Information Act, the Department of Revenue is allowed to share this information to the Internal Revenue Service.
Failing to supply this information may jeopardize or delay the issuance or your license or processing your renewal
application.
When working with required data reporting from Minnesota public school districts, PELSB will use your private or
confidential data only for purposes of confirming unique identity. PELSB staff having access to this data are only
those working directly with licensing or the data reporting systems.
Application for a Tier 4 Minnesota Educator License: May 2020 Page 5 of 12
Minnesota Educator License
Application for a Tier 4
PELSB
1021 Bandana Blvd. East,
Suite 222
Saint Paul, MN 55108-5111
General Information and Instructions: a partial or incomplete application packet will be returned to the applicant for
completion and resubmission. To ensure the submission of a complete packet, review and follow the instructions and
checklist.
A completed Conduct Review Statement must accompany every application.
If you have questions, call 651-539-4200, go to the website at https://mn.gov/pelsb/, or send an email to pelsb@state.mn.us
A check or money order payable to “PELSB” must be included. This is a non-refundable processing fee.
• Initial/First Time Minnesota Educator License Application Fee: $90.25 which includes fingerprint card fee.
Request a fingerprint card from PELSB. Include the completed fingerprint card with the complete application.
• Existing Minnesota License Holders Application Fee: $57.00 (does not require a fingerprint card).
Section 1: Applicant Information
MINNESOTA FILE
FOLDER NUMBER
Enter your MN File Folder
Number, if applicable.
REGISTER NUMBER (for state use only)
Last Name First Name Middle Name Previous Name
Social Security Number/ITIN (required) Birthdate: mm/dd/yyyy
Gender
(optional)
Male Female
Contact
Information:
Daytime Telephone Number Email Address (PELSB communications will be sent to this email address.)
Designated
Address:
Street City State ZIP Code
Home
Address:
Street City State ZIP Code
Ethnicity/Race
(optional)
American Indian Asian Black Hawaiian/ Pacific Islands
Hispanic/ Latino
White
Section 2: Application Type
Enter the name of the LICENSURE
FIELD(S) you are requesting:
CHECK HERE if you are adding a licensure field to an existing Minnesota Tier 4 license.
CHECK HERE if you are adding a licensure field to AND renewing an existing Minnesota Tier 4 license. All clock
hours must be reported before applying.
Section 3: Educational Background
Use the following
Degree Codes:
0 – No Degree 1 – Associate’s Degree 2 – Bachelor’s Degree 3 – 5
th
Year/Non-degree Program
4 – Master’s Degree 5 – Specialist 6 – Doctorate
College or University
Located at
(city and state)
Degree
Code
Date of
Degree
Degree Field
FOR STATE USE ONLY
College Code
Application for a Tier 4 Minnesota Educator License: May 2020 Page 6 of 12
Name File Folder Number
Section 4: Licensure Requirements
The applicant meets the educational or professional requirements:
1. Holds a bachelor’s degree (submit official transcripts in an institution’s sealed envelope; the degree must be
identified on the transcript),
2. And the applicant has obtained passing scores on the following Minnesota Teacher Licensure Examinations
(MTLE) and Basic Skills Exams OR is applying for a licensure field that does not require testing (School Counselor,
School Nurse, School Psychologist, School Social Worker, and Speech-Language Pathologist). Refer to the
Minnesota Teacher Licensure Testing Information
document for specific testing information.
(https://mn.gov/pelsb/assets/Teacher%20Licensure%20Testing%20Information_tcm1113-321360.pdf)
a. Basic Skills requirements met.
b. Pedagogy subtest 1 and 2 passed: aligned to grade scope (if the grade level requested is K-12, the applicant
can choose either the elementary OR secondary pedagogy tests, both grade levels are NOT required).
c. Content specific subtest 1 and 2, including subtest 3 for elementary education, passed and aligned to the
licensure content area (check here if the content area requested does not have a content test).
3. And demonstrates completion of one of the following (check at least one box below):
a. An approved Minnesota teacher preparation program – submit official transcript in an institution’s sealed
envelope with licensure program listed; complete Section 6.
A state-approved teacher preparation program outside of Minnesota that includes 12 weeks of full time
field-specific student teaching (the applicant is exempt from field-specific student teaching if the candidate
verifies completion of a state-approved teacher preparation program outside of Minnesota AND has two
years of field-specific teaching experience; include the Verification of Teaching Experience Form to qualify
for this exception) – submit official transcript with the licensure program listed; complete Sections 6 and 7.
c. Adding a licensure field to an existing Tier 4 license by recommendation through the Licensure via Portfolio
process (https://mn.gov/pelsb/aspiring-educators/portfolio/) – must use the PORTFOLIO application which
was provided with your letter of approval.
d. Adding a licensure field to an existing Tier 4 license which required completion of a teacher preparation
program, a professional teaching license from another state, evidence that the candidate’s license is in
good standing, and two years of teaching experience in the requested licensure field – submit a copy of
your license; complete Sections 6 and 7.
e. Applying for and providing evidence of meeting the requirements for one of the following related services
licensure fields: School Counselor, School Nurse, School Psychologist, School Social Worker, or Speech-
Language Pathologist.
4. And has three years of classroom teaching experience, as the teacher of record, in a Minnesota school,
5. And is not currently on an improvement plan, based on the most recent summative evaluation (pursuant to
Minnesota Statutes 122A.40, subdivision 8 or 122A.41
, subdivision 5).
b.
Application for a Tier 4 Minnesota Educator License: May 2020
Page 7 of 12
Conduct Review Statement
(required for ALL applications)
Last Name First Name Middl
e Name Previous Name
File Folder Number Social Security Number/ITIN (required)
Birthdate: mm/dd/yyyy FOR STATE USE ONLY
You must answer all questions completely and provide all requested information. Failure to answer any of the questions
in a truthful manner or failure to provide the information requested could lead to denial of any educator license. If you
are completing the conduct review for a renewal of or addition to an existing Minnesota license, only disclose incidents
that have occurred since your last license was issued.
Check the appropria
te boxes below. If there is any writing on this form, it cannot be scanned properly and your
application will be delayed. If you are submitting additional information, you must use either the Supplemental
Information Form or other sheets of paper.
Yes No 1. Have you ever been convicted of a crime?
A “crime” means conduct which is prohibited by statute and for which the actor may be sentenced
to imprisonment, with or without a fine. Crimes include misdemeanors, gross misdemeanors, and
felonies. DWIs and DUIs are included in this definition and must be disclosed. Do NOT include petty
misdemeanors in your disclosures as these are not crimes.
The term “conviction” includes a finding of guilt by a jury or judge, an admission of guilt or a plea
of guilty, an Alford plea (a plea without admission of guilt), a plea of “no contest,” and/or charges
that have resulted in a stay of imposition of sentence. If your criminal conviction has been
expunged by a court order, you do NOT need to disclose the conviction; however, you may first
wish to verify if your conviction is subject to full expungement versus a court records expungement
(“inherent authority expungement”). Inherent authority expungement orders do not prohibit
convictions from showing up on a background check. Convictions subject to an inherent authority
expungement need to be disclosed.
If you answered “yes,” complete and include the Supplemental Information Form (Section 5B) and
attach it to this page.
Yes No 2. Have you ever been referred to a pre-trial diversion program after being arrested?
If you answered “yes,” complete and include the Supplemental Information Form (Section 5B) and
attach it to this page.
Yes No 3. Have you ever been acquitted, found not guilty, or given a stay of adjudication of a criminal
offense involving sexual conduct, homicide, assault, or any other crime involving violence?
If you answered “yes,” complete and include the Supplemental Information Form (Section 5B) and
attach it to this page.
Application for a Tier 4 Minnesota Educator License: May 2020 Page 8 of 12
Name File Folder Number
CONDUCT REVIEW STATEMENT continued
Yes No 4. Are any criminal charges currently pending against you in Minnesota or any other state (this
includes a pending stay of adjudication)?
If you answered “yes,” you must complete the Supplemental Information Form (Section 5B) and
attach it to this page.
Yes No 5. Have you ever been the subject of a harassment restraining order, a domestic assault no contact
order, an order for protection, a temporary restraining order, or similar civil protective order in
Minnesota or any other state?
If you answered “yes,” you must attach materials explaining the type of protective order, the date
action was taken, the final order document, the court file number, and the court/county involved.
Yes No 6. Have you ever been found in violation of a harassment restraining order, a domestic assault no
contact order, an order for protection, a temporary restraining order, or similar civil protective
order in Minnesota or any other state?
If you answered “yes,” you must complete the Supplemental Information Form (Section 5B) and
attach it to this page.
Yes No 7. Have you ever been the subject of a maltreatment finding or disqualification by the Minnesota
Department of Education, the Minnesota Department of Human Services, a county human services
office or similar agency in Minnesota or another state?
If you answered “yes,” you must attach materials explaining the type of action, the date action was
taken, the final order document, and the agency involved.
Yes No 8. Have you ever had an education or other occupational license revoked, suspended, denied, subject
to a stayed suspension/probation, or received a formal reprimand in Minnesota or any other
state?
If you answered “yes,” you must attach material explaining the type of license, the date action was
taken, the final decision document, and the agency involved.
Yes No 9. Have you ever voluntarily surrendered or terminated an education or other occupational license
because of misconduct?
If you answered “yes,” you must attach material explaining the basis for the
surrender/termination, type of license, location, date of surrender/termination, and agency
involved.
Yes No 10. Is disciplinary action/a misconduct investigation against your teaching, administrative, or other
occupational license currently pending in Minnesota or another state?
If you answered “yes,” you must attach material explaining the action or charges, location, date,
status of investigation and board/employer involved.
Application for a Tier 4 Minnesota Educator License: May 2020 Page 9 of 12
Name File Folder Number
CONDUCT REVIEW STATEMENT continued
Yes No 11. Have you ever been terminated, suspended, resigned from or otherwise left an employment
position after allegations of misconduct were made against you or when an investigation into
those allegations was pending?
If you answered “yes,” you must attach material explaining the action or charges, location, date,
and employer involved.
Yes No 12. Have you or a school district in which you were employed ever been a party to a civil settlement,
award, or agreement of any kind that involved an allegation that involved YOUR sexual conduct?
If you answered “yes,” you must attach material explaining the situation including the date and
location of the school district.
WARNING: FAILURE TO ANSWER ANY OF THE ABOVE QUESTIONS IN A TRUTHFUL MANNER OR FAILURE TO PROVIDE THE
INFORMATION REQUESTED COULD LEAD TO DENIAL OR DISCIPLINARY ACTION BEING TAKEN AGAINST ANY EDUCATOR
LICENSE.
Certification of Information
I certify the foregoing information is true and correct. I hereby authorize any listed courts and law enforcement agencies
identified in this application to release any information concerning me to the Minnesota Professional Educator Licensing
and Standards Board (PELSB).
Signature of Applicant Date
Application for a Tier 4 Minnesota Educator License: May 2020 Page 10 of 12
Section 5B: Supplemental Information Form
(required only if you answered “YES” to questions 1. 2, 3, 4 or 6)
Please photocopy and complete a separate form for each conviction or outstanding charge.
1. Convicted or currently charged with:
2. Level of offense (check one):
Felony
Gross Misdemeanor
Misdemeanor
3. Date of offense:
4. Name of arresting agency (police, county sheriff, etc.):
5. Court jurisdiction (i.e., Hennepin County District Court, Minneapolis, Minnesota):
6. Plea and conditions of probation, if any:
7. Date of release from probation:
8. If still on probation, name and telephone number of probation officer:
9. Details of incident:
Verification/Authorization of Information
I verify the foregoing information is true and correct. I hereby authorize the above listed courts and law enforcement
agencies to release any information concerning me to the Minnesota Professional Educator Licensing and Standards Board.
File Folder Number Printed Name Date of Birth
Signature of Applicant Date
Application for a Tier 4 Minnesota Educator License: May 2020
Name File Folder Number
Verification of Completion of a State-Approved Licensure Program
This section is to be completed by the state-approved licensure program certification officer.
The state-approved teacher preparation program is from
OUTSIDE of Minnesota AND is (check all that apply):
The state-approved teacher preparation program is:
a regionally accredited program a Minnesota state-approved program
an alternative preparation program
Student Teaching/Practicum/Internship
For special education, include the ages/grade levels AND specific disability categories (with the severity levels: mild,
moderate, severe, and/or profound) of students served in each placement. License issuance may be delayed without this
information.
School/Organization Licensure Field(s)
Grade Level(s)
Taught
Dates
Start End
Licensure Program Completed
For special education licenses, please identify the specific disability category.
Subject/Licensure Field Grade Levels
Date Preparation
Program Completed
Print Name of Certification Officer or Registrar Title
Email Address for Certification Officer or Registrar Telephone Number for Certification Officer or Registrar
Name of Institution Location (city, state, ZIP code)
Signature of Certification Officer or Registrar Date
Page 11 of 12
Name File Folder Number
Section 7: Verification of Teaching Experience
All initial Tier 4 applicants are required to provide documentation of three years of work experience in a Minnesota
school.
If you are applying for a Tier 4 license for a School Counselor, School Nurse, School Psychologist, School Social Worker,
or Speech-Language Pathologist, you are required to provide evidence of three years of work experience in a Minnesota
school.
District/School Name
Location
(city, state)
Dates of
Employment
Percentage
Fulltime
Specific Subject(s) Taught
Grade
Level
Taught
Start End
I confirm this information is correct.
Name of District or Charter School Six-Digit District Number (XXXX-XX) (only
required for Minnesota schools)
Mailing Address (city, state, ZIP code)
Printed Name of Authorized Official Email Address
Signature of Authorized Official Date Ten-Digit Telephone Number
Application for a Tier 4 Minnesota Educator License: May 2020
Page 12 of 12
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