Educator Preparation Institute
Alternative Certification Program

Application

Student ID#:	Email address:	Date:
Last Name:	First Name:	Middle Initial:
Local Street Address:	City:	State:	Zip:
Permanent Street Address:	City:	State:	Zip:
Home Phone:	Work Phone:	Mobile Phone:
1) Please indicate your degree and major: Bachelor's: Ph. D.: Master’s: Ed. D. Major:
2) What level do you plan to teach? ECE (Pre-school – 3^rd Grade): Elementary (K-6): Middle School (6-9): High School (9-12):
3) When did you first seriously consider teaching as a career? Before High School High School Later/Career Change
4) How did you hear about the Educator Preparation Institute and the Alternative Certification Program? Student Teacher Advisor Presentation News article Poster Brochure Website Other
5) Have you completed the application process with the Florida Department of Education for a temporary Certificate? Yes No
6) If so, do you have a Statement of Status Of Eligibility (SOE)? Yes No
7) In which county (ies) are you planning to teach?
8) If currently working in a school system, in what capacity? What county? Capacity: County:
9) You will need to complete a law enforcement background check prior to entering classes within the school districts. Law enforcement background checks may be completed by contacting the school district office before field experience. (See EPI Coordinator for details)

Personal identifying information will be treated as confidential and not disclosed to any third party except as required or authorized by law.