Form 24 "Application for Kansas Limited Apprentice License" - Kansas

What Is Form 24?

This is a legal form that was released by the Kansas Department of Education - a government authority operating within Kansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 23, 2021;
  • The latest edition provided by the Kansas Department of Education;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 24 by clicking the link below or browse more documents and templates provided by the Kansas Department of Education.

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Download Form 24 "Application for Kansas Limited Apprentice License" - Kansas

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TEACHER LICENSURE AND ACCREDITATION - K ANSAS STATE DEPARTMENT OF EDUCATION
24
APPLICATION FOR KANSAS
LIMITED APPRENTICE LICENSE
CHECKLIST FOR SUBMITTING A COMPLETE APPLICATION
ALL THREE SECTIONS (Sections A - C) must be submitted together along with the application fee.
SECTION A: Applicant
Pages 3-6 fi lled out completely by applicant and signed.
SECTION B: Employing School System
Pages 7-8 fi lled out completely by employing school system and signed.
Coordinate submission with the applicant.
SECTION C: Institution
Pages 9-10 fi lled out completely by institution and signed.
Coordinate submission with the applicant.
Plan of Study: Filled out completely by institution and signed.
APPLICATION FEE
Check or money order for $65 made payable to the Kansas State Department of
Education.
Choose ONE:
Check
Money order
MAIL ALL SECTIONS and APPLICATION FEE to:
KSDE
Attention: TLA
900 S.W. Jackson Street, Suite 106
Topeka KS 66612-1212
Fingerprint Card
If needed, fi ngerprint card and fee can be submitted (see Fingerprint Instructions on page 11).
Fingerprint card and fee may be submitted separately.
Kansas leads the world in the success of each student.
1
Rev. June 23, 2021
TEACHER LICENSURE AND ACCREDITATION - K ANSAS STATE DEPARTMENT OF EDUCATION
24
APPLICATION FOR KANSAS
LIMITED APPRENTICE LICENSE
CHECKLIST FOR SUBMITTING A COMPLETE APPLICATION
ALL THREE SECTIONS (Sections A - C) must be submitted together along with the application fee.
SECTION A: Applicant
Pages 3-6 fi lled out completely by applicant and signed.
SECTION B: Employing School System
Pages 7-8 fi lled out completely by employing school system and signed.
Coordinate submission with the applicant.
SECTION C: Institution
Pages 9-10 fi lled out completely by institution and signed.
Coordinate submission with the applicant.
Plan of Study: Filled out completely by institution and signed.
APPLICATION FEE
Check or money order for $65 made payable to the Kansas State Department of
Education.
Choose ONE:
Check
Money order
MAIL ALL SECTIONS and APPLICATION FEE to:
KSDE
Attention: TLA
900 S.W. Jackson Street, Suite 106
Topeka KS 66612-1212
Fingerprint Card
If needed, fi ngerprint card and fee can be submitted (see Fingerprint Instructions on page 11).
Fingerprint card and fee may be submitted separately.
Kansas leads the world in the success of each student.
1
Rev. June 23, 2021
FORM 24 I A P P L I C AT I O N F O R K A NS A S L IMI T ED A P P R EN T I C E L I C ENSE P R O G R A M
For more information, contact:
Kansas State Department of Education
900 S.W. Jackson Street, Suite 102
Topeka, Kansas 66612-1212
Teacher Licensure and Accreditation
(785) 296-2288
(785) 296-3201
(785) 296-7933 - fax
www.ksde.org
The Kansas State Department of Education does not discriminate on the basis of race, color, national origin, sex, disability or age in its programs and activities and provides equal
access to the Boy Scouts and other designated youth groups. The following person has been designated to handle inquiries regarding the nondiscrimination policies: KSDE General
Counsel, Office of General Counsel, KSDE, Landon State Office Building, 900 S.W. Jackson, Suite 102, Topeka, KS 66612, (785) 296-3201.
2
Rev. June 23, 2021
SIGN
LEGAL
CONSULTANT
FEE
TEACHER LICENSURE AND ACCREDITATION - K ANSAS STATE DEPARTMENT OF EDUCATION
EXPIRE
FP IN
24
APPLICATION FOR KANSAS
RAP
SENDBACK
LIMITED APPRENTICE LICENSE
M&E
VERIFIED BY
WALK-IN
SECTION A: TO BE COMPLETED BY THE APPLICANT
Complete all data fi elds and answer all professional conduct questions.
Social Security Number
Birthdate (MM/DD/YYYY)
Gender:
Male
Female
_______________________________________________________
_______________________________________________________
Legal name: First name
Middle name
Last name
_________________________________________________
_________________________________________________
_________________________________________________
All prior names (Maiden, alias, previous married, etc.)
_________________________________________________________________________________________________________________________________________________________
Mailing address
_________________________________________________________________________________________________________________________________________________________
City
State
Zip
______________________________________________________________
_________________________________________________________
_____________________________
Phone
Alt Phone
Email address
___________________________________________
___________________________________________
_______________________________________________________________________________
Ethnicity (mark only if applicable)
Race (mark one or more as applicable)
White
Native Hawaiian or Other Pacifi c Islander
Hispanic/Latino
American Indian or Alaska Native
Asian
Choose not to designate
Black or African American
1. Are you or your spouse a current member of any branch of the United States Armed Services (Army, Marine Corps, Navy, Air Force,
Space Force or Coast Guard) U.S. military reserves or any state's National Guard?
Yes (If yes, skip to question 5 on page 4.)
No (Continue to question 2.)
2. Are you or your spouse a former member of any branch of the United States Armed Services (Army, Marine Corps, Navy, Air Force,
Space Force or Coast Guard) U.S. military reserves or any state's National Guard with an honorable discharge?
Yes (If yes, skip to question 5 on page 4.)
No (Continue to question 3.)
3. Are you a current resident of the state of Kansas?
Yes (If yes, skip to question 5 on page 4.)
No (Continue to question 4.)
4. Do you intend to establish residency in the state of Kansas?
Yes
No
Kansas leads the world in the success of each student.
3
Rev. June 23, 2021
FORM 24 I A P P L I C AT I O N F O R K A NS A S L IMI T ED A P P R EN T I C E L I C ENSE P R O G R A M
5. PLEASE READ THE FOLLOWING QUESTIONS VERY CAREFULLY. Failure to accurately answer these questions or submit
appropriate documents will delay the issuance of your license. Unless expunged, you are required to disclose both adult and
juvenile off enses.
a. Have you EVER been convicted of a felony?
If yes, please attach a certifi ed copy of the following documents:
Yes
• Charging document
No
• Journal entry of conviction
b. Have you EVER been convicted of ANY crime involving
Yes
If yes, please attach a certifi ed copy of the following documents:
theft, drugs or a child?
No
• Charging document
• Journal entry of conviction
c. Have you EVER entered into a diversion agreement
Yes
If yes, please attach a certifi ed copy of the following documents:
or otherwise had a prosecution diverted after being
• Charging document
charged with any felony or any crime involving theft,
No
• Diversion agreement
drugs or a child?
• Journal entry closing that case
d. Are criminal charges pending against you in any state
Yes
If yes, please attach a certifi ed copy of the
involving any felony or any crime involving theft, drugs
• Charging document
or a child?
No
e. Have you had a teacher’s or school administrator’s
Yes
If yes, please indicate the action taken:
certifi cate or license denied, suspended, revoked or
been the subject of other disciplinary action in any
No
Denied
state?
Suspended
Revoked
Which State(s):________________________________________________________
Please attach a copy of the documents regarding the offi cial
action taken.
f. Is disciplinary action pending against you in any state
Yes
If yes, please attach a copy of the offi cial documents regarding
regarding a teacher’s or administrator’s certifi cate or
the action pending against you.
license?
No
g. Have you ever been disbarred or had a professional
Yes
If yes, please indicate the action taken:
license or state issued certifi cate denied, suspended,
revoked or been the subject of other disciplinary
No
Denied
action regarding any profession in Kansas or any other
Suspended
state?
Revoked
Which State(s):________________________________________________________
Please attach a copy of the documents regarding the offi cial
action taken.
h. Have you ever been terminated, suspended or
Yes
If yes, which school system(s)? _______________________________________
otherwise disciplined by a local Board of Education
for falsifying or altering student tests or student test
No
When? ________________________________________________________________
scores?
i. Have you ever falsifi ed or altered assessment
Yes
If yes, which state(s)? _________________________________________________
data, documents or test score reports required for
licensure?
No
When? ________________________________________________________________
4
Kansas State Department of Education |
www.ksde.org
Rev. June 23, 2021
FORM 24 I A P P L I C AT I O N F O R K A NS A S L IMI T ED A P P R EN T I C E L I C ENSE P R O G R A M
ASSURANCES
1.
I verify that I have a minimum of one full school year as a full-time special education paraprofessional under the supervision of a
special education teacher.
The paraprofessional experience was completed in this school system: ________________________________________________________
2.
This school system has employed me in an appropriate special education position:
______________________________________________________________________________________________________________________________
3.
I am completing the limited apprentice high incidence special education program through this university:
______________________________________________________________________________________________________________________________
4.
I have been provided a plan of study by the university and understand which coursework needs to be completed each semester.
a.
I have completed the fi rst semester (minimum of at least 6 credit hours) from my plan of study.
b.
I am currently enrolled in second semester coursework from the plan of study.
5.
I have earned degree(s) from the following college/university:
LAST TERM OF ATTENDANCE
YEAR
STATE
NAME OF COLLEGE/UNIVERSITY
DEGREE
EARNED
TERM
YEAR
_____________
___________________________________________________________________
_________________________________
___________
_____________
______________
_____________
___________________________________________________________________
_________________________________
___________
_____________
______________
_____________
___________________________________________________________________
_________________________________
___________
_____________
______________
_____________
___________________________________________________________________
_________________________________
___________
_____________
______________
SIGNATURE AND DATE REQUIRED
I certify that I am of good moral character and that the information on this application is true and complete to the best of my knowledge. I
understand that any misrepresentation of facts may result in the denial or revocation of my certifi cate or license.
I hereby grant the permission and authorize the Kansas State Department of Education to verify all responses with any mental health facility or
governmental agency, including a release of any information concerning myself in the child abuse and neglect central registry records, and to
obtain and review all records maintained by any criminal justice agency, including a criminal history record information check, regarding any of
my criminal charges, adjudications or convictions, and to contact previous employers for information regarding the term of my employment. I
hereby release, discharge and exonerate the Kansas State Department of Education, its employees and any person so furnishing information
from any and all liability of every nature and kind arising out of the furnishing of such records and information. I understand that any material
submitted in connection with this application will become the property of the Kansas State Department of Education, and may be considered a
public record.
AND
I hereby give my employing school system and verifying licensing institution permission to release any and all information needed.
Applicant name (please print)
Last 4 digits of Social Security number
_
Signature of applicant
Date
SEND ORIGINAL SIGNED FORM 24 - NO PHOTOCOPIES ACCEPTED
5
Kansas State Department of Education |
www.ksde.org
Rev. June 23, 2021
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