Name: Last First Middle All application material must be submitted to:

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1 Teacher Certificatin Prgram Entry Reuirements Checklist The cmpleted applicatin, PACT scres, fficial transcript(s), must be received by August 1 fr Fall entry r December 15 fr January entry. There will be a nn- refundable $80 applicatin fee cllected upn registratin. Incmplete applicatins will nt be reviewed. Nte: In the case that yu are nt accepted, yur file will be kept fr tw years then destryed. Reuirements fr prgram entry may change based n State Bard fr Educatr Certificatin rules. Name: Last First Middle All applicatin material must be submitted t: ACC Teacher Preparatin Prgram Attentin: Sandra J Nix 5930 Middle Fiskville Rd Austin, Texas sandra.nix@austincc.edu FAX: Minimum Reuirements fr All Applicants Pass the Pre-Admissin Cntent Test (PACT) in cntent area where yu are seeking certificatin Admissin_Cntent_Test/ Bachelr s degree frm an accredited cllege/university with a minimum f 2.5 GPA verall r in the last 60 semester credit hurs Official university/cllege transcripts frm all institutins f higher learning that yu attended sent directly t ACC Teacher Certificatin Prgram shwing cursewrk, number f subject hurs, verall GPA, prf f Bachelr s degree, and any advanced degrees frm an accredited university. Transcripts shuld be ed digitally r mailed directly t ACC Teacher Preparatin Prgram, attentin: Sandra J Nix at address abve. N phtcpies will be accepted. (D NOT send transcripts t ACC Admissin and Recrds.) If transcripts are frm a freign cuntry, they must be evaluated by a TEA Vendr and the evaluatin must state that yur degree is eual t an American university s Bachelr s degree OR the cuntry is listed n the TEA website as an English speaking cuntry; A list f TEA recgnized vendrs can be fund at Out-f- State_Certificatin/Freign_Credential_Evaluatin_Services/ If the language f instructin frm the ut-f-cuntry cllege/ university is nt English r the cuntry is nt listed n the TEA website as English speaking, yu must take and pass all sectins f the TOEFL exam with minimum scres f Speaking 24, Listening 22, Reading 22, Writing 21. TOEFL scres are valid fr tw (2) years frm the test date. Fr mre infrmatin: State_Certificatin/English_Language_Prficiency/

2 Interview (Once yur cmpleted applicatin and all material has been submitted, an interview will be scheduled by the ACC teacher certificatin prgram staff.) In additin t the abve minimum reuirements, be sure that yu meet the fllwing technical standards: Ability t cmplete reuirements independently Ability t understand and implement directins Valid address and regular access t a cmputer Financial ability t pay prgram fees and tuitin by deadlines 1

3 Seeking Admissin: Fall 2018 Teacher Certificatin Prgram Applicatin Spring 2019 Please print in ink if nt cmpleted nline. Scial Security Number Date: Name: Last First Middle Indicate ther identifying name(s) that may appear n yur dcumentatin: Date f Birth: Gender: Male Female Mnth/Day/Year Address: Street City State Zip Daytime Phne Number: Evening Phne Number address: Current Schl (if emplyed): Select ne certificatin: Cre Subjects EC-6 (TExES 291) Schl Name Schl District Cre Subjects 4-8 (TExES 211) Math 4-8 (TExES 115) Math 7-12 (TExES 235) Math/Science 4-8 (TExES 114) Science 4-8 (TExES 116) Science 7-12 (TExES 236) Special Educatin EC-12 (TExES 161) Technlgy Applicatins (TExES Special Educatin reuires ne ther The fllwing infrmatin is fr reprting purpses t prvide statistical infrmatin reuested by varius State and Federal agencies: Ethnicity: Hispanic/Latin (Cuban, Mexican, Puert Rican, Suth r Central American, r ther Spanish culture) Nt-Hispanic/Latin Race (check ne): American Indian r Alaska Native rigins in any f the riginal peples f Nrth and Suth America (including Central America), and wh maintains a tribal affiliatin r cmmunity attachment Black / African American rigins in any f the black racial grups f Africa Asian rigins in any f the riginal peples f the Far East, Sutheast Asia, r the Indian subcntinent, including, fr example, Cambdia, China, India, Japan, Krea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam Native Hawaiian / Pacific Islander rigins in any f the riginal peples f Hawaii, Guam, Sama r ther Pacific Islands White rigins in any f the riginal peples f Eurpe, the Middle East r Nrth Africa Tw r mre races Austin Cmmunity Cllege des nt discriminate n the basis f age, gender, race, clr, creed, religin, natinal r ethnic rigin, disability, r veteran status in the administratin f its emplyment practices, educatinal r admissin plicies, schlarships r lan prgrams, athletic r ther schl-administered prgrams.

4 BACKGROUND INFORMATION Are yu eligible t wrk in the United States? N Yes Have yu served in the military? N Yes Branch Frm T!3

5 Educatin: Minimum Bachelr s Degree Overall GPA is (Must be stated n transcripts) All Clleges/ Universities Attended City and State Type f Degree Granted Majr/ Minr DATES: Frm T Have yu ever been admitted int anther teacher certificatin prgram? Yes N If yes, prgram cntact infrmatin: Name f Prgram: Address: Phne Number: Why did yu leave that prgram? Did yu leave the prgram in gd standing? Yes N Check any f the bxes that apply: Certificatin/Permit Texas Prbatinary Certificate Texas Intern Certificate Valid Out-f-State Teaching Certificate Texas Emergency Permit Date Issu Expires: Subject(s): Other D yu pssess a certificate which is currently suspended, revked, r pending such actin in any state? If yes, explain: D yu have a Texas Educatin Agency identificatin number? Yes TEA ID # N Emergency Infrmatin: Please prvide at least tw emergency cntact individuals. Name Relatinship Phne Number!4

6 Authrizatin fr Criminal Backgrund Check Ntice t Teacher Certificatin Applicants Austin Cmmunity Cllege District has cntracted with LexisNexis Screening Slutins, Inc. a third party private investigatins agency t verify certain infrmatin cntained in yur applicatin fr admissin t the Teacher Certificatin prgram.. The infrmatin reuested belw is necessary t cmply with federal and state regulatins. This infrmatin is a part f the applicatin fr admissin t the Teacher Certificatin Prgram and will be used fr the sle purpse f verificatin f infrmatin and/statements made by yu. Please cmplete all infrmatin reuested: Applicant s Legal Name Last Name First Name M.I. Current Hme Address Street City/State Zip Cde DATE OF BIRTH: SOCIAL SECURITY #: Mnth/Date/Year Residential Histry: List all residential addresses in the last 7 years # f years at this address Address City/State Zip Cde # f years at this address Address City/State Zip Cde # f years at this address Address City/State Zip Cde It is pssible that yur admissin t the teacher certificatin prgram may be determined by using data frm a reprt supplied by LexisNexis Screening Slutins Inc., P.O. Bx , Philadelphia, PA Pursuant t Sectin 609 f the Fair Credit Reprting Act, yu may be entitled t a cpy f this reprt. APPLICANT CONSENT: I understand and agree that ACC will verify all r part f the infrmatin I have given. I understand that this verificatin may include any inuiry int my credit histry, criminal and civil recrds, prir emplyment, as well as ther public recrd infrmatin. I authrize release f such infrmatin as may be necessary t verify the infrmatin I have prvided. I release and hld harmless frm all liability any individual r entity reuesting r supplying infrmatin with respect t my applicatin t the teacher certificatin prgram. I understand that Austin Cmmunity Cllege District may deny me admissin t a prgram that invlves minr children if I have a pertinent misdemeanr r felny cnvictin APPLICANT SIGNATURE: DATE:!5

7 AUTHORIZATION FOR CRIMINAL BACKGROUND CHECK (Nte t Applicants) Backgrund: T btain yur teaching certificatin, yu must be hired t teach, and having a criminal histry may keep yu frm emplyment. Accrding t H.B (TEC21.917), Texas schl districts will run a Criminal Backgrund Check (CBC) t btain criminal histry infrmatin n every emplyee, candidate fr emplyment, and bserver in schls. The State Bard fr Educatr Certificatin will als run a fingerprint check. A criminal histry may keep yu frm emplyment with a schl district AND frm acceptance int the Teacher Certificatin Prgram. Yu are eligible fr a pre-determinatin f teacher certificatin by cnsulting the Texas Educatin Agency at Preliminary_Criminal_Histry_Evaluatin-FAQs/ Have yu ever been cnvicted f a crime ther than a traffic ticket r parking vilatin? N Yes If yes, n the space prvided belw, state the crime/s, lcatin f the curt where yu were cnvicted, date f cnvictin and current dispsitin r status, including length f prbatin, parle, fine r time served. Attach additinal sheets if necessary. **Have yu received deferred adjudicatin fr a crime? N Yes Nte: yu must answer yes, even if yu have cmpleted the deferred adjudicatin and yu have been advised r d nt feel that the crime is r shuld be reflected n yur recrd. If yes, n the space prvided belw, state the crime/s, lcatin f the curt where yu received deferred adjudicatin, date, and a current dispsitin r status. Attach additinal sheets if necessary. **If yu have received deferred adjudicatin fr a crime, we encurage yu t cntact a lawyer t have the incident expunged frm yur recrd. Please attach additinal sheets if necessary I certify that all f the abve infrmatin is true, accurate, and cmplete. I understand that any misrepresentatin r willful missin f facts shall be sufficient cause fr disualificatin f this applicatin frm further cnsideratin. Signature f Applicant: Date!6

8 FEES All fees are eligible fr ACC s installment plan except the Applicatin Fee. Extra fees will be reuired fr exams, textbks, certificatin fees, etc. If yu intern ut f the ACC district, yu will be expected t pay an additinal $250/semester fr supervisin expenses. Certificatin Prgram Curses and Fees Cst Applicatin fee nnrefundable $80 EDTC 3000 Pedaggy and Prfessinal $1500 Respnsibilities EDTC Methds fr Special Ppulatins $500 EDTC - Managing the Classrm $500 EDTC - Digital Literacy $500 EDTC XXXX - Summer Cntent Specific Classes $500 EDTC Supprting the Teaching Experience fr $500 EDTC Successful Teaching Practices fr Reading $500 EDTC Fall Internship $1000 EDTC 3006 Clinical Teaching*** ************** EDTC Spring Internship $1000 TOTAL **** EDTC 3006 Clinical Teaching $1000 Nte: Please make a cpy f all applicatin material fr yur recrds. $6,260 Thank yu fr chsing Austin Cmmunity Cllege as yur teacher certificatin prgram!!7

9 REFUNDS The ACC Cntinuing Educatin refund plicy: 100% prir t the weekday befre the first class day, and 100% if class is canceled by ACC. After classes begin, cnsult the table belw. The number f days listed refers t business days (M-F), nt class meeting days. YOU MUST CONTACT THE TEACHER CERTIFICATION STAFF IN WRITING FOR WITHDRAWAL FROM THE PROGRAM, LEAVE OF ABSENCES, ETC. Class Length in Weeks Last day fr 70% Last Day fr 25% 2 r fewer 2 N/A r mre Payments must be made by deadlines, r yu will pay an additinal $25 late fee and may be drpped frm the prgram. Cntact the Teacher Certificatin Office at with any uestins r fr registratin. Refund Prcessing: ACC mails refund checks t the address n file at the cllege. Check with Cntinuing Educatin registratin staff t verify current and accurate infrmatin befre the refund prcess is started. Credit card refunds will appear n yur mnthly statement as sn as pssible after the fficial reprting date. Yu are respnsible fr interest charged t the credit card accunt while the refund is prcessed. (This may take up t six weeks.) ACC charges a $25 prcessing fee fr any refunds that are reissued. Each curse will be taught as listed, prvided enrllment in each sectin justifies the ffering. The schedule f time, rm and instructr reflects ur intent at the time f publicatin. Curse fferings and prices are subject t change, and the listing is nt a guarantee that they will be ffered exactly as listed. Payment Methds: Credit card payments (Visa, MasterCard, and Discver Card) accepted in persn, by telephne , r mail the registratin frm alng with yur check r mney rder t: Austin Cmmunity Cllege, Center fr Teacher Certificatin, 5930 Middle Fiskville Rd., Austin, TX Returned Items: A $25 fee will be charged and a hld will be placed n accunts with any f the fllwing: * Checks returned stp pay r accunt clsed and credit card charge backs. Yu will be drpped frm all classes and be liable fr the returned check fee and any nn-refundable fees. Checks returned unpaid (NSF) must be replaced by cash r a mney rder. Otherwise, returned checks will be referred t a cllectin agency, which may assess further charge!8