Kutztown University
College of
Education
Post-Baccalaureate
Certification
Application
When Completed Return To:
Kutztown University
College of Education
231 Beekey Education Center
Kutztown, PA 19530
APPLICATION FOR ADMISSION INTO
POST-BACCALAUREATE INITIAL TEACHER CERTIFICATION PROGRAM
Thank you for your interest in Kutztown University Post-Baccalaureate Initial Teacher Certification program. This program is a nondegree program designed to provide students already holding a Bachelor of Arts or a Bachelor of Science degree from an accredited
institution to receive an initial teacher certificate or an extension of certification. Please direct all questions to the Dean’s Office at 610683-4332. The deadline for Spring is November 1 and for Fall July 1.
Please forward your completed application to the College of Education Dean’s Office for admission into the Post Baccalaureate Initial
Certification program. Kutztown University, College of Education Dean’s Office, P.O. Box 730, Kutztown, PA 19530.
Option 1: Admitted to the Post Baccalaureate Certification Program:
 $35.00 application fee payable to Kutztown University.
 3.00 Cumulative Grade Point Average (C.G.P.A.) at the undergraduate level.
 Clearances: Act 34 Criminal History, Act 151 Child Abuse and Act 114 FBI Federal Criminal history reports. (All of the
clearances have to be in process when you apply)
Option 2: Conditional Acceptance status to the Post Baccalaureate Certification Program: If you have NOT completed ALL of the
above your next option includes:
 $35.00 application fee payable to Kutztown University.
 *Take 9 program specific credits with a "B" or better assigned by the department chair or designee. Once the courses are
completed your application will be reviewed. (Approved by the Council of Teacher Education, October 15, 2009)
If you do not have any of the following they must be completed by the deadline stated by the department chair or designee.
 Praxis I or PAPA testing (if not already completed and on file at Kutztown University).
 Clearances: Act 34 Criminal History, Act 151 Child Abuse and Act 114 FBI Federal Criminal history reports.
*NOTE: You need to have a 3.00 G.P.A. in all of the course work above if not done so at the baccalaureate degree level.
Date of Application _________________________ Semester and Year for which you are applying: Fall ________ Spring ________ Year ________
Social Security # _______________________________ PHONE: (Home) (
) ____________________ (Cell) (
) ____________________
Mr.
Name: Mrs.____________________________________________________________________________________________________________
Ms.
First
Middle
Last
Maiden
Include other name(s) under which academic records held _________________________________________________________________________
Permanent Address________________________________________________________________________________________________________
Street
City
State
Zip Code
County
E-Mail Address: __________________________________________________________________________________________________________
Place of Birth _______________________________________ Date of Birth ________________________ Sex: Male _________ Female ________
Are you a U.S. Citizen?  Yes
Visa Type: Student F1 ________
 No
If no, which country? _________________________________________________________________
Permanent ________
Alien (card #) ________________________ Other __________________________
(Non resident aliens, please photostat copy of green card)
Military Status: Non Veteran ______________________________ (0)
Veteran __________________________________ (1)
Emergency Contact: _______________________________________________________________________________________________________
Name
Address
Zip Code
Emergency Telephone Number (
) _______________________________________ Relationship ____________________________________
IMPORTANT:
Please mail with your application all sealed official copies of College/Universities transcripts you attended.
If you attended Kutztown University we will accept unofficial copies along with the application.
If you already possess a teaching certificate please send a copy of your certification.
For Office Use:
Student ID#_________________________________________
POST BACCALAUREATE CERTIFICATION*
PLEASE CHECK ONE SPECIFIC CERTIFICATION AREA DESIRED BELOW.
NOTE: You MUST already hold an Elementary Education Certificate to choose Special Education Post Baccalaureate program.
_____ Special Education MPH Pre K-8
* Applications for certification programs in ELEMENTARY SCHOOL COUNSELING, SECONDARY SCHOOL COUNSELING,
READING SPECIALIST, ELEMENTARY EDUCATION and SECONDARY EDUCATION must be obtained from the Office of
Graduate Studies. http://www2.kutztown.edu/academics/graduate-programs.htm
FEDERAL AND STATE REGULATIONS REQUIRE THAT THE FOLLOWING INFORMATION BE COLLECTED. YOUR
COOPERATION IS APPRECIATED.
PLEASE CHECK: ___ American Indian/Alaskan Native ___Asian/Pacific Islander ___Black/African American
___Native Hawaiian/Pacifica Islander ___Hispanic or Latino ___Non-Hispanic ___Not Specified ___White
Effective Spring 2011 Instructional 1 certification student needs to be registered for all required Praxis II or
PECT test prior to entrance into a Clinical Experience class. The teacher candidate will have to show the registration test
ticket to the department secretary in order to be cleared for the Clinical Experience.
PLEASE NOTE:
I testify that the information given in this application is both truthful and correct. I authorize you to use my social security number for
student identification records. ___________________________________________________________________________________
Signature of Applicant
NOTICE:
Kutztown University of Pennsylvania A Member of the State System of Higher Education Notice of Availability of Annual Safety
& Security/Fire Safety Reports
Kutztown University is committed to assisting all members of the community in providing for their own safety and security. The annual
security report and crime statistics and fire safety and fire statistics are available at: http://clery.kutztown.edu.
This report includes statistics for the previous three years concerning reported crimes that occurred on-campus, in certain off-campus
buildings or property owned or controlled by Kutztown University, and on public property within, or immediately adjacent to and
accessible from, the campus. This report also includes institutional policies concerning campus security and fire safety awareness,
inclusive of policies concerning sexual assault. You can obtain a copy of this report by contacting the Department of Public Safety &
Police Services at one of the following:
Mailing address: Kutztown University, Public Safety & Police Services, P.O. Box 730 Kutztown, PA 19530
Phone/Fax: 610-683-4002/610-683-1530
Email: publicsafety@kutztown.edu
FOR APPLICANT USE:
OPTION 1 Check Off List:
 35.00 application fee payable to Kutztown University.
 Official transcript(s) submitted in a sealed envelope College/University transcripts. Unofficial if you attended Kutztown
University.
 3.00 C.G.P.A. at your undergraduate level.
 Clearances: Act 34 Criminal History, Act 151 Child Abuse and Act 114 FBI Federal Criminal History reports (All of the
clearances have to be in process when you apply).
OPTION 2 Check Off List for what is completed:
 $35.00 application fee payable to Kutztown University.
 Official transcript(s) submitted in a sealed envelope College/University transcripts. Unofficial if you attended Kutztown
University.
 3.00 C.G.P.A. at your undergraduate level.
 Clearances: Act 34 Criminal History, Act 151 Child Abuse and Act 114 FBI Federal Criminal History reports (All of the
clearances have to be in process when you apply).
FOR OFFICE USE ONLY
DEAN’S OFFICE
$35.00 Application Fee ___________________
Clearances
Transcripts
TB Testing
Act 34
Act 151
Act 114
FOR DEPARTMENT CHAIR USE ONLY
Semester to start:______________
Accepted
Assigned Advisor: __________________________________
_________________________________________________
Department Chair Signature
____________________
Date
Conditional Acceptance
Conditions:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Assigned Advisor: __________________________________
_________________________________________________
Department Chair Signature
Revised 05/2015
My Documents: Application Post Bac
____________________
Date
Office of Clinical Experience & Outreach
General Information regarding all Background Checks

Use your home address ( not school ) when applying for all Background Checks
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Keep all original background checks in a secure location
Keep hard copies of all Background Checks to use for observations
Never relinquish original background checks to anyone
Out-of-state students must secure all background checks in Pennsylvania
If you have any arrest or conviction on any Background Check you must come to
the Office of Clinical Experience & Outreach immediately (Beekey 224).
(Failure to disclose this information may prevent you from completing Clinical Experience.)
Upon entering Kutztown University all Education Majors must bring hard copies of all Background Checks to the Clinical
Experience Office (Beekey 224) for approval prior to uploading on TaskStream. All are due within 30 days from the beginning
of the semester you enter KU.
When uploading your Background Check documents to TaskStream, please use PDF format ONLY. You will receive an e-mail via
TaskStream for re-submission of any document not in PDF format.
UNDERGRADUATE, GRADUATE AND TRANSFER STUDENTS MUST SUBMIT THE FOLLOWING BACKGROUND CHECKS:

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Act 34 Criminal History Report
Act 151 Child Abuse History Report
Act 114 FBI Federal Criminal History Record
Act 24 Arrest/Conviction Report
TB Test
 Act 34 ~ Criminal History Report
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Apply online at https://epatch.state.pa.us (secure website)
Click ‘Submit New Record Check’ and under reason for, click ‘Education’
$10.00 fee charged to credit card
Immediately print out results and keep this form for scanning and posting on TaskStream.
 Act 151 ~ Child Abuse History Report (Form CY 113)
Form available online: http://www.dhs.state.pa.us/findaform/childabusehistoryclearanceforms/index.htm
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Apply online with a $10.00 fee
DEPARTMENT OF PUBLIC WELFARE (address at top left of form)
Immediately print out results and keep this form for scanning and posting on TaskStream.
 Act 114 ~ FBI Federal Criminal History Record (Fingerprinting must be completed through COGENT, not State Police)
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Register and pay online at www.cogentid.com then click PA, Dept. of Education
(No cash or personal checks)
Fee: currently $27.50 (Subject to change & includes an unofficial copy of the report)
o Applicant will receive a Registration ID Number marked “Step #3 – Registration Complete” DO NOT
destroy this document – print this document and take it with you when you are fingerprinted
Click on ‘Cogent Sites’ to see locations closest to you. Site must be in Pennsylvania.
KU Bookstore is an authorized COGENT site!
“Civil Applicant Response - Unofficial Copy” will be mailed to your home address in about 5-7 days
Upon receipt of the “Civil Applicant Response - Unofficial Copy” keep this form for scanning and posting on
TaskStream
 Act 24 Arrest/Conviction Report (Form available on TaskStream)
 Complete this form and keep it for scanning and posting on TaskStream
 TB Testing
 TB testing may be administered by your private health care provider/family physician
or the KU Health & Wellness Center

Results may be submitted on a script pad or doctor’s letterhead with your name, results, date and the original
signature of your physician (no name stamps may be used)
 Keep this form for scanning and posting on TaskStream
Applicable to Student Teacher Candidates ONLY
All the above listed Background Checks must be renewed according to the dates given to you at the Pre-Registration
Meetings for Clinical Experience. All results must be approved by the Clinical Experience Office prior to uploading on
TaskStream. In addition you are responsible for the following:
 TB Test Completed within 90 (ninety) days of first placement; no earlier! Bring test results to OCEO
 Student PSEA Insurance (Not submitted on TaskStream)
Card must be presented to the Clinical Experience Office in person
 Apply online at http:/psea.org (Apply after April 1 for Fall; September 1st for Spring)
o Click “Join PSEA” – Click ”College Student” – Click “Join Online”
o Complete this process and print out two receipts
 Immediately submit a copy to the CE&O Office
 Fee charged is $30.00 + (subject to change)
 Membership year runs September 1 through August 31

Mandated Child Abuse Reporter Training www.reportabusepa.pitt.edu NO COST Online Training Print out
certificate and bring a copy to the Clinical Experience Office. Keep certificate with your Background Checks!

PSSA Training Module www.pssatraining.com. NO COST Click on the registration tab to the far right. (Select the IU,
District, and School that corresponds to your second placement if known.) If you are unable to find this information in
the dropdown menu, then list XXXXX as your district. Once registered, complete the online module. You cannot
proceed to different sections of the module without first completing the section you have begun. When you complete
the module print out the certificate for future use. Bring a copy of the certificate to the Clinical Experience Office.
Keep certificate with your Background Checks!
Please direct questions to the
Office of Clinical Experience & Outreach (OCEO)
224 Beekey Education Center
610-683-4256 / 4276