DATE
Department of Public Instruction
Emergency Renewal Request
Name
Address
Phone Number
Email Address
DPI file/entity number
I am requesting a renewal of my emergency license in (list subject and age range/developmental range
– example: ESL ages 6-13 Middle Childhood through Early Adolescence), but was unable to complete
the required 6 credits for renewal due to (list your circumstances).
I understand that, if you were to approve me, I am responsible for either completing my certification
program or completing any credits I missed this year in addition to the required 6 credits for the
following year’s renewal. Here is my plan:
Fall 2014
List each course prefix, number, title, credits and school you will be taking the course through.
( Example: Education 331 Instructional Technology, 3 credits – UWSP)
Spring 2015
List each course prefix, number, title, credits and school you will be taking the course through.
Summer 2015
List each course prefix, number, title, credits and school you will be taking the course through.
NOTES:


Make sure to indicate any tests you are required to take in the term you will take them.
Make sure to list every term, course and test you will need to do until you would complete the
entire program