Application For CEOE Participation

APPLICATION FOR CEOE PARTICIPATION

Please complete this online application form and submit it. You may send a résumé (optional) and/or any other documents that support your application (e.g., letters of reference, commendations) to the Evaluation Systems group of Pearson, P.O. Box 226, Amherst, MA 01004-0226, or fax to (866) 565-4877 (toll free).

1. Name:
Prefix (Dr., Mr., Ms.)
First Initial Last

2. School/Institution Affiliation:

3. School District:

4. Work Address:

Street/P.O. Box
City
State/Province
ZIP

5. Home Address:

Street/P.O. Box
City
State/Province
ZIP

6. Preferred address for correspondence:
Home Work/School

Phone Numbers (no spaces or dashes; for example, "4055551212"):

7. Work Phone:	Ext.	8. Home Phone:
9. Fax Number:		10. Cell Phone:

11. E-mail Address (work):

Confirm E-mail Address (work):

12. E-mail Address (home):

Confirm E-mail Address (home):

13. Your Title:

14. Current Position		15. Most Recent Grade Level Taught		16. Level of Education (highest attained)		17. Years of Teaching Experience
	Early Childhood		K		Bachelor's Degree		0–3 years
	Elementary		1–3		Master's Degree		4–6 years
	Middle School		4–6		Doctoral Degree		7–10 years
	Secondary		7–8				11 or more years
	Vocational		9–12
	College Level: Teacher Education Faculty		College Level: Teacher Education Faculty
	College Level: Other Than Teacher Education Faculty		College Level: Other Than Teacher Education Faculty

18. Are you currently teaching in an Oklahoma public school (PK–12)? Yes No (Last year of teaching: )

19. What are your current public school (PK–12) teaching assignment(s)?

20. Are you certified to teach in Oklahoma public schools? Yes No

21. Are you a National Board for Professional Teaching Standards certified teacher? Yes No

22. Are you certified to teach in public schools in another state? Yes No

23. Geographic Region (refer to map)
	Northwest
	Southwest
	Northeast
	Southeast
	Oklahoma City
	Tulsa
24. Student Population of District
	Less than 500
	501–1,000
	1,001–5,000
	5,001–10,000
	Over 10,000

25. Area(s) of Oklahoma educator certification:

26. Are you currently a faculty member of an Oklahoma university? Yes No

27. What is your primary academic departmental affiliation (e.g., English dept.)?

28. Have you had experience with teacher education candidates/majors not yet ready for student teaching, student teachers, or entry-level educators?

Yes No

29. How recently have you had experience with teacher education candidates/majors not yet ready for student teaching, student teachers, or entry-level educators?

Within the last 3 years 4 or more years ago

30. Are you a recent graduate (within the past 5 years) of an approved Oklahoma teacher preparation program?

Yes No

31. Professional organization(s) of which you are a member (list up to three):

32. Languages other than English in which you are proficient:

33. Please list any other relevant experiences and/or achievements that support your application (e.g., other committee work, test development or test scoring activities, curriculum development activities, research, publications) 255 characters maximum:

34. For your primary teaching area, have you completed an academic major in this field OR have you passed an Oklahoma subject matter test in this field? (Oklahoma subject matter tests have been offered since 1982.)

Yes No

PERSONAL INFORMATION

The Oklahoma Commission for Teacher Preparation (OCTP) is committed to having diversity amongst individuals participating in the CEOE program and appropriate representation of racial and ethnic groups, men and women, and individuals with disabilities. To enable the OCTP to accomplish this goal, you are asked, but not required, to provide the information on this form.

Ethnicity (check all that apply):	Gender:
Native American or Alaskan Native	Male
White, not of Hispanic origin	Female
Hispanic
African American, not of Hispanic origin
Asian/Pacific Islander
Other

Do you have a disability? No Yes (please specify):

I certify that the above information is accurate to the best of my knowledge.