NCCU School of Library and Information Sciences

Application for a Professional Education License
By a CPL Completer at NCCU

Please Read Carefully and Complete EVERY Item

1. Name:
Last Name:
First Name:
Middle Name:
2. Mailing Address
(for license):
(Individual, school, or school system to receive license)
Street: Apt. #:
City: State: Zip:
3. Statement of Applicant: Have you ever been convicted of a felony or crimes other than minor traffic offenses? Yes No
If the answer is yes, give the date, name of the ofense, the trial court- including city and state, and any other pertinent information on a separate sheet of paper.
I hereby certify that the information giveon on this application is correct and true. I understand that the falsification of any statement on this application will constitute grounds for the revocation of my North Carolina teaching license.
Applicants Signature:
Date of Birth: Gender: Male Female
Social Security Number: Race or Ethnic Origin: Black White Native American/Alaskan Native Asian/Pacific Islander Hispanic Multi-racial
Home Phone #: Work Phone #:
4. Program:
Licensure Program:
Concentration: (Elementary, Middle & PE only)
Degree Type: Bachelor (first degree) Master No Degree (licensure only)
License Class: Bachelor (A) Master (G)
License Type: Initial Add-on Upgrade
5. Student Status:
Are you employed in NC with
a current clear license? Yes No If Yes, list the area(s) 
a current lateral entry or provisional license? Yes No If Yes, list the area(s) 
a current temporary permit? Yes If Yes, list the area(s) 
Are you licensed by NC DPI? Yes No  
Enrollment Status: Part-Time Full-Time
6. Previous Education: (Post-secondary degrees held):
Degree Major Institution Completion Date
Degree Major Institution Completion Date
Degree Major Institution Completion Date
Degree Major Institution Completion Date
7. Required Materials for Your Licensure Packet:

a. Did you successfully complete directed teaching? Yes No If No, see 6b-c. If Yes, attach Form IHE-01B (rec. of cooperating teacher) and skip to 6d.

b. If you did not complete directed teaching because you are teaching on a lateral entry or provisional license, attach the appropriate license or agreement letter.

c. If you did not complete directed teaching because you have had appropriate experience (e.g., in private schools), attach documentation of experience — letters(s) from principals/supervisors and approval letter from NCCU School of Education.

d. Attach copy of your ETS score reports of all required Praxis/NTE exam results. (None needed for upgrading in same area.)

e. Are you a licensure-only or second-degree student or graduate student applying for an initial license? Yes No If Yes, attach legible, degree-dated undergraduate transcripts — originals or duplicates. If No, continue.

f. Attach the licensure fee of $55, a check — personal, cashier's, or money order — made out to LICENSURE SECTION — NCDPI (unless you are clearing a current lateral entry or provisional license).

The Licensure Officer will obtain your official NCCU transcript. When all paperwork is assembled and processed in house, it will be sent to the NC Department of Public Instruction where it will take 4-8 weeks (or longer) to process.

8. Submission of Application: Complete this form and return it, with the materials indicated, to the School of Library and Information Sciences, North Carolina Central University, PO Box 19586, Durham, NC 27707. The School will check the application, and when complete, forward it to the NCCU Licensure Office, 110 Taylor Education Building, NCCU.

9. Plans for Employment or Advanced Study: If you have secured a teaching or other position (including a continuing position) or have been admitted to a graduate or professional school, please indicate.

Employer Institution
Position Field of Study
Address of School/Employer
Date Application Submitted: