Wisconsin Department of Public Instruction
DISTRICT REQUEST FOR SPECIAL EDUCATION
AIDE LICENSE
PI-1622-Aide (Rev. 02-19)
Telephone: 608-266-1027 or
800-266-1027
Website: http://dpi.wi.gov/tepdl
This forms is available at:
http://dpi.wi.gov/tepdl/elo/supplementary-forms
Instructions for the Applicant: You must submit this form to your employing school district so they may complete the request section
below. After the completed form has been returned to you, scan the document and upload when applying for your Special Education
Program Aide License in the ELO (Educator Licensing Online) system.
Instructions for the Employer: Complete the request and return the completed form to the applicant.
APPLICANT INFORMATION
Legal Name Last, First, Middle Social Security Number* Last 4 Digits Only
Other / Previous Names
ADMINISTRATOR INFORMATION
School District
Requested Start Date
July 1,
Name of Administrator First and Last Name Email Address of Administrator
SIGNATURE
I, THE EMPLOYING ADMINISTRATOR, request that the Department of Public Instruction issue a Special Education Program Aide license to the
above-named applicant.
Signature of Employing Administrator
Date Signed Mo./Day/Yr.
*Collection of social security number is a requirement of s.118.19(1m) and 1(r). It is used solely for validation purposes and will not be released
without written permission.
click to sign
signature
click to edit
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