SSN:	--
Name:
Address:
City:
State:
Zip Code:
Email:
Home Phone Number:	-
Alternate Phone Number:	-
Gender:	Male Female
Birth Date:	//
Are you a U.S. citizen?	Yes No
If not, country of cizitenship and type of visa:
Optional Information
Are you Hispanic or Latino?	Yes No
What is your race? (Check one or more)	White Black or African American Asian American Indian or Alaskan Native Native Hawaiian or other Pacific Islander
Term Applying For:	Fall Spring
Admission Desired:	Track I: I hold a Temporary Provisionary Certificate Track II: I hold a Bachelor's Degree in a certifiable major
Kentucky teaching certificate desired:	Secondary 8-12 Middle 5-9 Art P-12 Business Marketing 5-12 Theater P-12 Spanish P-12
Your college major field(s):
List in chronological order all colleges or universities attended:
Name of Institution	City/State	Degree	Dates Attended (From - To)
Current employment (Job and Employer):
If your current job is teaching, what is the content area?
Grade Level?
School?