Form Pi 1602 El PDF Details

In an effort to support educational institutions in moments of unforeseen staffing shortages, the Wisconsin Department of Public Instruction has formulated a streamlined process for obtaining emergency licenses and permits, specifically designed for circumstances where a fully-licensed candidate is unavailable despite diligent search efforts. The PI-1602-EL form plays a crucial role in facilitating this process, serving as the primary document for applying or renewing emergency licenses and permits, including those for long-term substitutes. Applicants, on the brink of stepping into vital roles, are encouraged to provide detailed and legible information, ensuring the swift procession of their applications. Submission of this form, well-complemented by the necessary documentation and application fee, initiates a comprehensive review led by the Department. Applicants are advised against sending applications via fax and are instead directed to mail all materials to a designated address for processing. This approach underscores the Department's commitment to maintaining high standards in emergency staffing solutions, ensuring that even in the face of unexpected vacancies, the quality of education provided to students remains uncompromised.

QuestionAnswer
Form NameForm Pi 1602 El
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesWisconsin, fphelp, Notarization, NCLB

Form Preview Example

Wisconsin Department of Public Instruction

FOR MORE INFORMATION:

LICENSE APPLICATION

Telephone No.

(608) 266-1027 or 1-800-266-1027

EMERGENCY LICENSE OR PERMIT

Web Site

dpi.wi.gov/tepdl

 

 

PI-1602-EL (Rev. 06-10)

We do not accept applications by FAX.

Page 1

 

 

 

 

 

 

 

 

WE WANT TO DO AN EXCELLENT JOB FOR YOU. HERE IS HOW YOU CAN HELP.

Use the correct form. Use the PI-1602-EL form to apply for or renew emergency licenses and permits (including long-term substitutes) which are requested by an employing school district after a search for a fully-licensed candidate was conducted and was unsuccessful. For more information, go to: http://dpi.wi.gov/tepdl/emerg.html

Emergency Licenses: Applicant is licensed (or eligible for licensure) in Wisconsin, however, the emergency assignment is outside the applicant’s current licensure area.

Emergency Permits: Applicant did not complete an educator preparation program. Bachelor’s degree from an accredited institution is

required.

Do not use this form to apply for a three-year short-term substitute permit. Use the PI-1602-SP form instead.

Do not use this form for a school board requested 1-year administrator license. Use the PI-1602-AD1 form instead.

Type or print legibly in black or blue ink. Do not submit “back-to-back” photocopies since pages of the application are separated during processing. Keep a copy of your entire application including all documentation since no documents can be returned to you.

Mail all necessary documentation and forms, including the PI-1602-A Conduct and Competency Review (and fingerprint cards if required), along with the application and fee payment in one complete submission. This will facilitate much faster processing of your application.

Verify the date that the application was received at DPI by checking the License Lookup at: dpi.wi.gov/tepdl/lisearch.html

LICENSE APPLICATION INSTRUCTIONS

I.Applicant Information: Fill in all boxes. “Primary Telephone” is a number to contact you from 8 a.m. to 4 p.m. Central Time.

II.Type of Emergency License or Permit: Part A—Answer all pertinent questions. List the subject and developmental or grade level information. Indicate whether this is a first time or renewal request. Part B—Applicant signature is required.

III.School District Request and Justification: The school district administrator or designee must complete Section III including justification/NCLB questions. The administrator of the district where the assignment is located must sign verifying the accuracy of the information provided and the responses to the NCLB highly qualified questions (when applicable).

IV. Institutional Verification: Required for renewal of a 1-year emergency license or permit. The institution or program provider must verify enrollment and completion of credits in an approved program leading to licensure in the subject and/or developmental/grade level for which the emergency licensure is requested. See special application mailing instructions at bottom of this page.

PAYMENT INSTRUCTIONS

Fee payment of $100 must be mailed with your application. Since the fee covers costs of application review and processing, NO REFUNDS WILL BE MADE, regardless of whether or not a license is issued. Fee is subject to change without notice.

CHECK OR MONEY ORDER: Make payable for $100 to: Dept. of Public Instruction. Do not mail this page (page 1) if paying by check or money order. Attach the check or money order securely to the front of page 2 of this form (the page containing applicant information).

CREDIT CARD: Fill in account information below. We accept only MasterCard and VISA credit cards (No check/debit cards). This credit card payment page must have an original signature and will be retained by our bank. This page is not forwarded to DPI licensing consultants, so be sure the reverse side does not contain any information needed to process your application. Attach this page on top of all other application materials.

 

 

 

Credit Card Account Number

 

 

 

MasterCard

 

 

 

VISA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Applicant Name If different than card holder

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Amount

 

 

 

 

 

 

 

Type or Print Cardholder Name

 

 

 

Credit Card Expiration Date

 

 

$100

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

 

 

 

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAILING INSTRUCTIONS (Do not FAX.)

All application materials and payment must be mailed (regular 1st class U.S. mail only) to DPI’s bank for payment processing before the

application can be reviewed. The bank then couriers application materials to Madison for processing by licensing consultants. Do not mail or

fax applications to DPI’s Madison office. If sent to Madison, review of your application will be significantly delayed. Applicants for a FIRST TIME 1-year emergency license or permit must mail the application packet to:

DPI Educator Licensing, Drawer 794, Milwaukee, WI 53293-0794

Applicants RENEWING a 1-Year Emergency License or 1-Year Permit (including long-term substitute license/permit) must mail the entire application packet (including forms, payment, and documentation) to the institution of higher education’s certifying officer. After completing

and signing Section IV, the certifying officer will send the application packet to the DPI address above.

Wisconsin Department of Public Instruction

LICENSE APPLICATIONEMERGENCY LICENSE OR PERMIT

PI-1602-EL (Rev. 06-10)

Page 2

FOR MORE INFORMATION:

Telephone No. (608) 266-1027 or 1-800-266-1027 Application Forms: dpi.wi.gov/tepdl/applications.html

Mailing Address: Do Not FAX the application.

DPI Educator Licensing

Drawer 794, Milwaukee, WI 53293

I. APPLICANT INFORMATION

Legal Name First

Middle

 

Last

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Previous Name(s)

 

 

Social Security No.* or Ed. File No.

 

Date of Birth Mo./Day/Yr.

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

P.O. Box

 

 

 

 

 

 

 

 

 

 

City

 

 

 

State

ZIP Code

 

 

ZIP Plus 4 digits

 

 

 

 

 

 

 

 

Primary Telephone (include area code)

Ext.

Alternate Telephone (include area code)

 

Ext.

 

 

 

 

 

 

 

 

 

 

 

Email Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current District of Employment

 

 

 

 

Most Recent Wisconsin Educator License

 

 

 

 

 

Issue Year

 

Expire Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

II.TYPE OF EMERGENCY LICENSE OR PERMIT

Applicant Completes Parts A & B

PART A – Please answer all that apply:

1)

I have already completed an educator training program

Yes (if yes, answer question # 2)

No (if no, skip to question # 3)

2)

I hold or have held a Wisconsin educator license

Yes (if yes, skip to # 4)

No (if no, answer # 2a)

 

2a. I have applied for regular licensure in Wisconsin

Yes (If yes, skip to # 4)

No (if no, answer question 3

If no to 2a, answer question 3 and submit with this application a PI-1612

Institutional Endorsement form available at: dpi.wi.gov/tepdl

3) I have attached original transcripts from an accredited college (http://ope.ed.gov/accreditation) verifying a bachelor’s degree

 

 

 

 

Yes (if yes, skip to # 4)

No (if no, answer # 3a)

 

3a. I have previously submitted these transcripts

Yes (if yes, answer # 4)

No

 

 

 

 

If no to 3a, answer # 4 and attach original transcripts to this application

 

 

 

 

or send them to: DPI Educator Licensing, PO Box 7841, Madison, WI 53707

 

 

 

 

 

 

 

4) This emergency assignment is in:

Subject(s)

 

 

Dev. Level/Grade(s)

This application is a:

 

 

 

 

 

 

First time request for an emergency license/permit

OR

 

 

 

 

 

 

Request for renewal of an emergency license/permit (Part IV – Institutional Verification is required.)

PART B—Applicant’s Verification

I UNDERSTAND that issuance or denial of an emergency license/permit is at the discretion of the state superintendent. Renewal of an emergency license/permit is considered only if the school district administrator requests renewal and satisfactorily explains the need, and if six semester credits (or equivalent) in an approved program leading to licensure in the assignment are satisfactorily completed between the begin date of the emergency license/permit and August 31st of the year the license/permit expires. Part IVInstitutional Verification must be completed for renewal requests.

Applicant Signature

Date Signed Mo./Day/Yr.

For DPI Use Only

FP

Conduct

 

For Bank Use Only

Amount of Remittance

Date Stamp

$100

*Collection of social security number is a requirement of s. 118.19(1m) and (1r). The social security number may be released to the Department of Justice, Department of Revenue, and the Department of Workforce Development. Such information is made available to these governmental agencies for official purposes only.

Page 2B

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PI-1602-EL (Rev. 8-10)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

III. SCHOOL DISTRICT REQUEST AND JUSTIFICATION FOR EMERGENCY LICENSE OR PERMIT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CESA No.

LEA No.

 

Requesting School District

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone Area/No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

School District Mailing Address Street or PO Box

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Z 3 Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

School No.

School Name Location of assignment

 

 

 

 

 

 

Charter School?

If Yes, check

School-wide Title I Building?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

box if Virtual

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Charter

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Wisconsin License(s) Requested

 

 

 

 

 

 

 

Dev. Level/Grade(s)

Targeted Title I Assignment?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Core Academic Subject(s) *

Title II-A Funded Position?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes**

 

 

No

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Percentage of School Day Teaching in Emergency Assignment(s)

 

 

Is the request for a Long-term Substitute Emergency License/Permit?

 

 

Full-time (teaching emergency subject(s) for the full school day)

 

 

Yes Assignment begin and end date must be provided

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part-time (teaching emergency subject(s) for part of school day)

Emergency request for this person in this assignment(s) is a:

 

 

 

 

 

 

 

 

 

 

Specify percentage of day teaching emergency subjects:

%

 

 

 

First Time Request

 

 

 

Renewal Request Must complete part IV.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Assignment Begin

Assignment End

Employee Name First, Middle, Last

Date Mo./Day/Yr.

Date Mo./Day/Yr.

 

SSN or DPI Educator File No.

*Core academic subjects defined under NCLB are English, reading or language arts, math, science, foreign languages, civics and government, economics, arts (all music licenses, art, theatre, dance), history and geography. Wisconsin includes elementary education, special education, ESL and alternative education as core academic subjects.

** NCLB requires that all teachers of core academic subjects must be “highly qualified.” As defined by NCLB, a teacher on an emergency license or permit in a core subject(s) is considered highly qualified ONLY IF:

Yes

 

No

1.

The educator has demonstrated content knowledge in the core subject(s) in which s/he will be teaching through either

 

 

 

 

 

 

a major,

 

a minor, or

 

successful completion of Wisconsin’s Praxis II content test(s); Attach documentation.

Yes

 

No

2.

The educator is enrolled in an approved educator preparation program that will be completed in three years;

 

 

 

 

 

Name of Institution or Alternative Route to Licensure Program:

 

 

 

 

 

 

 

Resulting Licensure:

 

 

 

 

Anticipated Completion Date: Mo./Yr .

 

 

 

 

 

 

 

 

 

Yes

 

No

3.

The district provides high quality professional development before and while teaching and intensive supervision or mentoring

 

 

 

 

 

while teaching.

 

 

 

 

 

 

 

 

Fully explain and justify the need for the request. Your justification is a determining factor in the issuance or denial of the request.

Attach additional 8 ½ x 11 sheet if necessary.

I ACKNOWLEDGE that the information above, the justification given, and the answers to the NCLB “highly qualified” questions (if applicable) are true.

Name of School District Administrator or designee Type/Print clearly

Title

Signature of School District Administrator or designee

Date Signed Mo./Day/Yr.

INSTITUTIONAL VERIFICATION

I, THE CERTIFYING OFFICER, CONFIRM that the applicant is enrolled in this institution’s (or alternative route to licensure program’s) state-approved

educator preparation program which is designed to be completed by

 

(Mo./Yr.) and within the last year the applicant has completed at least

six credits or the equivalent toward full licensure in:

 

(program).

 

 

 

 

 

 

Signature of Certifying Officer

 

Date Signed Mo./Day/Yr.

Name of Institution/Approved Program Provider

Wisconsin Department of Public Instruction

FOR INFORMATION: Phone (608) 266-1027

CONDUCT AND COMPETENCY REVIEW

Toll Free 1-800-266-1027

THIS FORM MUST BE SIGNED AND NOTARIZED.

 

PI-1602-A (Rev 06-10)

 

Forms available at: dpi.wi.gov/tepdl/applications.html

THIS FORM MUST BE COMPLETED AND SUBMITTED WITH YOUR APPLICATION.

Complete this form fully and truthfully and sign it in the presence of a notary public (most schools have a notary on staff). Carefully read all form instructions on the following page. An incomplete form will delay processing of your application.

Answer all questions 1-12. Use blue or black ink only. “Teaching” refers to all licensed school personnel including but not limited to teachers, pupil services personnel, administrators, library media specialists, substitute teachers, licensed aides, etc.

For any “Yes” answer to questions 1-11, include a detailed written explanation. Also submit complete copies of any related criminal complaint, criminal judgment, police reports, disciplinary letters/findings, correspondence etc. as applicable. Note: If you answered “Yes” to any question (1-11) on a previous DPI application and provided the necessary documentation to DPI at that time, check “PR” (Previously Reported) for that question, unless a new reportable incident(s) has occurred since then.

 

 

Yes

 

No

 

PR

1.

Have you ever been disciplined for alleged misconduct including but not limited to verbal, physical,

 

 

 

 

 

Previously

 

or sexual abuse or harassment in the course of any employment or as a member of any licensed or

 

 

 

 

 

Reported

 

regulated profession?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

PR

2.

Have you ever resigned, been disciplined or dismissed from any teaching or other school position, in

 

 

 

 

 

 

 

 

part, for alleged: (check any which apply )

 

immoral conduct or

 

incompetence?

(See Definitions.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

PR

3.

Have you ever had a certificate or license to teach or perform other school duties denied, revoked or

 

 

 

 

 

 

 

 

 

 

 

 

suspended?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

PR

4.

Is any investigation/discipline of your education related license or employment pending in any

 

 

 

 

 

 

 

 

 

 

 

 

jurisdiction?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

PR

5.

Have you ever been convicted of violating any civil, state, or federal law or local ordinance for

 

 

 

 

 

 

 

 

 

 

 

 

actions involving sexual conduct, physical abuse of a child, and/or contributing to the delinquency of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a child?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

PR

6.

Have you ever been convicted of any criminal offense (including

criminal

traffic matters, not general

 

 

 

 

 

 

 

 

 

 

 

 

traffic violations) in any jurisdiction? (check any which apply)

 

felony or

 

misdemeanor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

PR

7.

Have you ever participated in a deferred prosecution agreement to resolve a criminal matter?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

PR

8.

Are you currently on probation, parole, or other court-ordered supervision in any jurisdiction?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

PR

9.

Have you ever been acquitted or found not guilty by reason of insanity, mental disease or defect,

 

 

 

 

 

 

 

 

 

 

 

 

diminished mental capacity or comparable legal defense or basis of an offense involving sexual

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

conduct, or harm or threat of harm to another?

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

PR

10.

Is any investigation or criminal charge pending against you in any jurisdiction?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

PR

11.

Have you (or a school district where you worked) ever been a party to a civil settlement, award, or

 

 

 

 

 

 

 

 

 

 

 

 

agreement of any kind that involved an allegation concerning your conduct as an educator or in an

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

educationally related position or setting?

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

12.

Are you required to submit fingerprints to DPI with your license application? (See Instructions.)

 

 

 

 

 

 

 

 

 

 

 

 

 

If Yes, check one box below to indicate submission method. Provide date if cards are not enclosed.

 

 

 

 

 

 

 

 

 

 

Enclosed or

 

Mailed on

 

 

 

on

(date)

 

 

 

 

 

 

 

 

Two Cards

 

 

 

(date) OR Electronic Submission

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UNDER OATH, I swear that all information on this form and on the accompanying license application(s) and documentation is true to the best of my knowledge. Any false statements may result in denial, revocation, or suspension of license.

I HEREBY AUTHORIZE any of my previous employers, law enforcement agencies, and the courts to release, to the Wisconsin Department of Public Instruction, information which pertains to my responses to questions on this form.

Name Print or type

Signature (Sign in the presence of a Notary Public. Use blue or black ink.)

Social Security No.*

Sworn and signed before me this _____ day of _____________

in the year ____________.

__________________________________________________

Notary Public, _______________________________________

My commission expires on __________________________

*Collection of social security number is a requirement of s. 118.19(1m) and (1r). The social security number may be released to the Department of Justice, Department of Revenue, and the Department of Workforce Development. Such information is made available to these governmental agencies for official purposes only.

INSTRUCTIONS AND DEFINITIONS

CONDUCT AND COMPETENCY REVIEW FORM (PI-1602-A)

The Conduct and Competency Review Form is a screening method to protect children. While the vast majority of educators are not a danger to the safety and education of our children, there are exceptions to the rule. Some people use the profession to have access to children and to prey upon them. Because of these people, the department must

investigate the backgrounds of all license applicants. The questions contained in the conduct and competency review form have been developed to alert the department to cases that warrant further investigation. A “yes” answer to a question

or an arrest record does not automatically make you ineligible for licensure. Each situation is investigated independently and the final decision is made on a case-by-case basis. Your cooperation in protecting our children is greatly appreciated.

1.Answer all questions. We cannot issue a license unless all questions 1 - 12 are answered. Use black or blue ink only. Submitting a fully and correctly completed form with notarized signature will speed processing of your application.

2.Fingerprints: For question 12, carefully read ALL the criteria below to determine whether fingerprints are required in your situation.

You must answer Question 12. If you do not answer question 12, your conduct form will be returned to you for completion. If fingerprints are required, indicate how and when prints are being submitted. Fingerprints must be submitted electronically or prepared on cards obtained directly from the Department of Public Instruction (see dpi.wi.gov/tepdl/fphelp.html).

If you have worked, resided, or physically attended classes in a state other than Wisconsin, a listed territory (American Samoa, Guam, Puerto Rico, Commonwealth of the Northern Mariana Islands, or Virgin Islands), Canada, or Great Britain within the last twenty years after age 17, you must submit fingerprints with your license application.

Even if you previously submitted fingerprints to the Department of Public Instruction you must submit fingerprints again if, since the previous submission, you have worked, resided, or physically attended classes in any of the locations listed above. (If you previously submitted prints that met approved FBI/CIB standards and have not worked, resided, or physically attended classes in any of the locations above since submitting your prints to DPI, then new prints are not required.)

If your license application contains a non-Wisconsin mailing address, you must submit fingerprints.

Electronic Fingerprint Submission: The state of Wisconsin contracts with a specific private vendor to offer “inkless” live scan technology fingerprinting. This service is available only at specifically designated Wisconsin locations. If you are able to submit prints electronically through our vendor at one of the Wisconsin locations, you are not required to request fingerprint cards from DPI. More information about DPI-acceptable electronic fingerprint submission, including service locations, is available at: dpi.wi.gov/tepdl/fphelp.html.

Fingerprint Cards: If you do not submit prints electronically, you must request fingerprint cards from DPI by sending a request to dpifingerprints@dpi.wi.gov or by calling 1-800-266-1027. Cards and instructions will be mailed to you by U.S. mail. Be sure to

provide your name and complete mailing address including zip code in your request. You will be mailed two Federal Bureau of Investigation (FBI) cards preprinted with DPI’s code. Prints must be prepared, by a law enforcement official, on those cards.

NOTE: Incomplete or incorrectly prepared cards will be returned to you for resubmission until they are prepared as specified in the instructions provided. See dpi.wi.gov/tepdl/fphelp.html for instructions on completing the cards correctly.

3.Signature and Notarization Requirement: Your signature on the Conduct and Competency form must be notarized. If you do not sign the form or if your signature on the form is not notarized, your conduct form will be returned to you for completion. Notary Publics are available at schools and banks. Other options include a clerk or deputy clerk of a court of record, a court commissioner, a register or deputy register of deeds, a judge, or a county or deputy county clerk. For more information about notarization see Frequently Asked Questions about notarization at: dpi.wi.gov/tepdl/notary.html.

Definitions

“Immoral Conduct” means conduct or behavior that is contrary to commonly accepted moral or ethical standards and that endangers the health, safety, welfare, or education of any pupil. (Sec. 115.31(1)(c), Wis. Stats.)

“Incompetence” means a pattern of inadequate performance of duties or the lack of ability, legal qualifications or fitness to discharge required duties, and which endangers the health, welfare, safety or education of any pupil. (PI 34.35(1)(d), Wis. Admin. Code)

Reminders

Issuance or renewal of any license or permit by DPI is conditional pending the receipt of a satisfactory background investigation. (Sec. 118.19(10)(e), Wis. Stats.)

All information received from the Federal Bureau of Investigation and the Wisconsin Department of Justice as part of a background check, remains confidential. (Sec. 118.19(10)(f), Wis. Stats.)

You will be notified only if the department determines that the result of the background investigation is unsatisfactory.

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Part # 1 of filling out tepdl

2. Right after the last section is filled out, go on to enter the applicable information in all these: THIS FORM MUST BE SIGNED AND, PIA Rev, Forms available at, Complete this form fully and, THIS FORM MUST BE COMPLETED AND, Carefully read all form, Answer all questions Use blue or, teachers pupil services personnel, For any Yes answer to questions, Yes, PR Previously Reported, Have you ever been disciplined, Yes, Yes, and Yes.

Yes, PR Previously Reported, and Yes of tepdl

It is possible to get it wrong when filling out the Yes, and so ensure that you reread it before you decide to submit it.

3. Completing Fingerprints For question, If you have worked resided or, Guam Puerto Rico Commonwealth of, Even if you previously submitted, since the previous submission you, If your license application, information about DPIacceptable, locations, fingerprint submission, including service, Fingerprint Cards If you do not, NOTE Incomplete or incorrectly, and Signature and Notarization is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

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