Educator Application

National Private School Association
Application for Educator’s License
Please check one: ____ Certification (Does not currently hold NPSA License)
____ Re-certification (Currently holds NPSA License – current or expired)
______________________________________________________________________
Name: (Last)                   (First)              (Initial)            (Maiden)
Social Security Number _______________________
Email________________________________
Date of Birth ________________________________
Sex ___________
Home Address
___________________________________________________________________
(Street/Box) (City, State) (Zip)
NPSA School _________________________________________________________
NPSA Years Experience ________________ Total Years Experience ____________
Degree(s) Earned: ( ) Bachelors ( ) Masters ( ) Specialist ( ) Doctorate
Teaching Area: ( ) Administration
( ) Elementary Teacher Grade _________________________________
( ) Secondary Teacher Subject Area ____________________________
( ) Special Subjects Teacher Area __________________________________
( ) Full Time ( ) Part Time
Application must be accompanied by documentation of appropriate coursework.
Certification: This should include official college transcripts (verifying date of
graduation and degree earned), appropriate test scores (if applicable), and any teaching
certificates from the issuing agent of a state department of education.
Re-certification: Please complete the following and attach documentation to verify
completion.
Name of Course________________________________________________
Date Taken___________________
Location____________________________________
Name of
Course______________________________________________________________
Date Taken___________________
Location____________________________________
The undersigned acknowledges that he/she has never been convicted of any offense
other than a misdemeanor.
________________________ _____________________________________
(Date) (Signature of Administrator – new certification only)
________________________________________________
(Signature of Applicant)
The National Private School Association offers certification to all eligible candidates who are employed by member schools without discrimination in regard to sex, race, religion, physical handicaps, color or natural origin.