Wichita State University
Transition to Teaching Alternative Certification Program
June 2019 Cohort Application
Date of inquiry
Application for Academic Year
Personal Information
Last Name First Name
Street Address
City, State Zip Code
E-mail Address
Home Phone Work Phone
WSU ID # Social Security #
Undergraduate Degree Held
BA BS GS
Undergraduate Major
Date of Undergraduate Degree Receipt and the College/University (Month & Year)
Graduate Degree Held
MA MS MFA
MBA PhD
Graduate Major
Date of Graduate Degree Receipt and the College/University (Month & Year)
Grade Level You Would Like to teach
Middle School High School
Subject You Would Like to Teach
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Employment Information and History
Employer
Title/Position Dates: From/To
Employer
Title/Position Dates: From/To
Employer
Title/Position Dates: From/To
Please Respond to All of the Following Questions
Please identify and describe any experiences you have had working with middle or high school
age students. Include the setting and type of responsibility.
Please identify and describe any experiences you have had working in your content/degree
major field.
Please explain your reasons for applying to this program.
What do you believe are the biggest challenges that today’s secondary level teachers face and
how would you meet those challenges?
Teachers are responsible for the academic achievement of their students. What skills or
abilities do you possess that will help you ensure success for all students in your care?
ATTESTATION OF ELIGIBILITY
The Kansas State Board of Education requires that individuals who have been convicted of, or
pleaded guilty to, any act punishable as a felony may not be certified to teach. Wichita State
University is responsible for recommending individuals who have completed the teacher
education program for certification as a teacher. Given this responsibility, it is asked that you read
and sign the statement below.
If you are confident that you understand the standard, please answer the questions below and
complete the "Attestation of Eligibility."
1. Have you ever been convicted of a felony? Yes No
2. Have you ever been convicted on ANY crime involving theft, drugs, or a child?
Yes No
3. Have you entered into a criminal diversion agreement after being charged with any offense
described in Question 1 or 2?
Yes No
4. Are criminal charges pending against you in any state involving any of the offenses described
in question 1 or 2?
Yes No
5. Have you had a teacher’s or school administrator’s certificate or license denied, suspended or
revoked in any state?
Yes No
6. Is disciplinary action pending against you in any state regarding a teacher’s or administrator’s
certificate or license?
Yes No
7. Have you ever been terminated, suspended, or otherwise disciplined by a local Board of
Education for falsifying or altering student tests or student test scores?
Yes No
8. Have you ever falsified or altered assessment data documents, or test score reports required
for licensure?
Yes No
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If you answered “Yes” to any of the above questions, please describe your answers here:
ATTESTATION OF ELIGIBILTY
I, ________________________________________________, attest to the College of Education
at Wichita State University that I have not been convicted nor have I pleaded guilty for the
violation of any law punishable as a felony and I can answer “no” to questions 1-8 listed above.
Signature
Date
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