Form Pi 1602 El – Fill Out and Use This PDF

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Form Pi 1602 El PDF Details

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Question	Answer
Form Name	Form Pi 1602 El
Form Length	5 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 15 sec
Other names	Wisconsin, 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
EMERGENCY LICENSE OR PERMIT
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
	—								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 APPLICATION— EMERGENCY 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
		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 IV–Institutional Verification must be completed for renewal requests.

Applicant Signature



Date Signed Mo./Day/Yr.

For DPI Use Only

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

box if Virtual

Yes

Charter

Wisconsin License(s) Requested

Dev. Level/Grade(s)

Targeted Title I Assignment?

Yes

Core Academic Subject(s) *

Title II-A Funded Position?

Yes**

Yes

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

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

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

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

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
	CONDUCT AND COMPETENCY REVIEW	THIS FORM MUST BE SIGNED AND NOTARIZED.
		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

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

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

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

suspended?

Yes

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

jurisdiction?

Yes

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

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

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

Yes

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

Yes

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

10.

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

Yes

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

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

(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 __________________________

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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Yes, PR Previously Reported, and Yes of tepdl

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