Application for Certification Program Enrollment
Consult the accompanying instructions. Attach all materials requested.
Submit to the School of Education, UW-Stout, 267 HMEC, Menomonie, WI 54751
Date of Birth (mo/day/yr) __________________
Gender: ❏ Male ❏ Female
U.S. Veteran: ❏ Yes ❏ No
Personal Information
Social Security Number* __________________________ Stout ID Number __________________________
Last Name
First
Permanent Home Address
Mailing Address
Middle
Street and No.
Maiden (Prior)
City
Street and No. (No P.O. box) City
Current E-Mail Address
Permanent Phone
Country
Country
State/Zip
State/Zip
Home Phone
Cell Phone
Citizenship:
❏ United States Citizen
❏ Permanent Resident (immigrant)
Registration Number: ____________________
❏ Non-Immigrant Alien
Country (Non-USA): ______________________
* Use of SS# is optional if you have a UW-Stout ID number
Enrollment Information
Anticipated first enrollment (enter year)
Semester 1 – August 20_______
Semester 2 – January 20 _______
Racial/Ethnic Heritage:
❏ African American or Black
❏ American Indian or Alaskan Native
❏ Hawaiian or Pacific Islander
❏ Cambodian
❏ Hmong
❏ Laotian
❏ Vietnamese
❏ Other Asian
❏ Cuban
❏ Mexican, Mexican American, or Chicano/a
❏ Puerto Rican
❏ Other Hispanic, or Latino/a
❏ White or Caucasian
❏ Other (specify) __________________________
❏ I do not wish to provide this information
Winterm (3 wks) 20_______
Summer Session 20_______
WI DPI Certification Options through UW-Stout School of Education
Please check the certification and level (graduate/undergraduate) for which you are applying
GR UG
❏❏
Adaptive Education (859)
❏
Art (550)
❏❏ Biology (605)
❏❏ Broadfield Science (601)
❏❏ Business Education (250/281)
❏❏ Chemistry(610)
GR UG
❏❏ Driver Education (450)
❏ ❏ Early Childhood (777)
❏ Early Middle Childhood (777; PK-6)
❏❏ Early Childhood Special Ed (809)
❏ Economics (710)
❏❏ Family Consumer Education (210)
G R UG
❏❏ Health (910)
❏ History (725)
❏ Instruct Tech Coord (92)
❏ Loc Voc Ed CTE Coord (64/65)
❏❏ Marketing Ed (285)
❏ Math (400)
G R UG
❏ ❏ Physics (625) ❏ Reading (316) ❏ ❏ Special Ed Cross Cat (801) ❏❏ Special Ed Cog Dis (810)
❏ Speech (320)
❏❏ Technology Ed (220)
Residency
The following data is needed to determine if you should be charged in-state or out-of-state tuition. Criteria for determining residence status for tuition purposes are defined by
state law. A copy of the Wisconsin Statutes is available upon request. Please Note: It is your responsibility to register correctly, as a resident or non-resident, under the law.
Wisconsin resident? q Yes q No (list state of residence) ______________________________
If resident, how long have you lived in Wisconsin? Since ____ /____ (Month/Year)
When was the last year you filed Wisconsin income tax? 20____ (Year)
Indicate the dates you have lived at your present address. From: ____ /____ (Month/Year) to ____ /____ (Month/Year)
List former addresses (street, city, state, country) within the last two years:
________________________________________________________________________________________________ From: _______
________________________________________________________________________________________________ From: _______
Last Voter Registration (city, state, mo/yr)
Occupation, activity, school or employer and address
________________________________________________________________________________________________ From: _______
________________________________________________________________________________________________ From: _______
Parent’s name ___________________________________________________________________________________
Parents address (last 2 years) _____________________________________________________________________ From: _______
Have you, or your spouse or parent(s) recently moved to Wisconsin to accept permanent full-time employment? q Yes q No
To: _______
To: _______
To: _______
To: _______
To: _______
Education History
The following information is needed to determine which educational documents, if any, will be needed to complete your
application. List in chronological order all education beyond high school including any college, university, vocational-technical
school extension, or service schools and any degree(s) earned. Please be complete:
Name
Location
Dates
Degree or diploma (mo/yr awarded)
High School: _ _________________________________________________________________________________________________________________ Colleges: _ ____________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________ Application must be signed and dated to be processed.
I certify that I am applying to a specific certification, that the information in this application is true and complete to the best of my knowledge, and that I
understand that inaccurate information may affect my enrollment or financial aid status.
Signature: ____________________________________________________________________________
Date: ____________________________________
**$50.00 Transcript Review Fee (Except for students with a UW-Stout degree)**