The purpose of this form is to request an initial teacher or school service provider credential for the individual indicated below.

Instructions

1. Provide all information as required on the form. Incomplete forms shall not be accepted for processing.
2. This form must be signed by the hiring or employment verification official of the employing LEA.
3. Once completed, this form may be given to the employee so that he/she can add it to their application packet or email to [email protected].

Related Content: Educator Credentialing and Certification