Last Name First Name Initial Birthday (xx/xx/xx) SSN (xxx-xx-xxxx)
Requirements for Acceptance into the Teacher Education Program
1.
A minimum of 2.50 cumulative G.P.A.
2.
A total minimum of 2.50 GPA in University Seminar, College Writing and Quantitative Reasoning (Core) with no grade lower than a ‘C’ (a grade of ‘C-’ or lower is not acceptable).
3.
A record free of, “conviction of, entry of a guilty verdict, a plea of guilty, or a plea of no contest to a criminal offense involving moral turpitude in this state or any other state or country,” (Montana Annotated Code, Sec. 20-4-110).
In order to meet the requirement for question #3 (above), you need to answer the following questions: a.
Have you ever been convicted of a crime more serious than a minor traffic violation? This disclosure must be made irrespective of whether the record was sealed or expunged, you served a sentence and had your civil rights restored, the sentence was deferred or suspended, or the charge was dismissed after conviction.
Yes No
If your answer to the above question is a “Yes”, explain fully below, specifying the nature of the offense(s), the date(s) it/them occurred, the name and location of the court (s), and the sentence(s) imposed. This disclosure must be made irrespective of whether you served a sentence and had your civil rights restored.
Use additional pages if necessary. b.
Are you currently on probation, deferred prosecution, suspended sentence?
Yes No
If your answer to the above question is “Yes”, explain the circumstances and include the restrictions imposed by the courts. Use additional pages if necessary.
Schools will require a criminal records check before placement in public schools. MSU will receive your complete criminal record before placing students.
I hereby certify that the above information is true and correct, and I understand that any misrepresentations on this application may be grounds for denial of the application. By signing below, I acknowledge that all the information is accurate, and I give the Montana State University Education Department permission to verify any information provided.
____________________________________________________
Signature
_______________________________________
Date

ID:
Social Security #
Local Address:
Street
Name:
Last Name
Degree:
College Degree Completed
Subject #
HIST
105IH
Origins of Western Civilization
4
Course Title
HIST
107IH
Western Civilization: 1600-Present
4
HIST
110D
Latin America
4
HIST
155IH
America & Wrld Before 1865
4
HIST
156IH
America & the World after 1865
4
GEOG
105D
World Regional Geography
3
City
First Name
State
CR Grade Subject #
Take Two of the Following:
HIST
104D
World History
4
HIST
109D
Modern Asia
4
HIST
115D
History of Japan
3
Take Two of the Following:
HIST
Initial
Date: m/d/yr
Phone:
Zip
College Degree Sought
Course Title CR Grade

305
Mexico
3
HIST
316
History of Russia
3
HIST
318
History of Ancient Greece
3
HIST
319
History of Ancient Rome
3
HIST
323
Age of Absolutism & Reason
3
HIST
325
19 th Century Europe
3
HIST
326
20 th Century Europe
3
HIST
333
Early Britain: Prehistory to 1714
3
HIST
334
Modern Britain
3
HIST
335
Hist of Mid East in 20 th Century
3
HIST
361
History of Modern France
3
HIST
362
Modern Germany
3
HIST
368
20 th Century War: Vietnam Era
3
HIST
371
Take One of the Following:

Age of the Shoguns
3
HIST
372
Japan’s Long 19 th Century
3
HIST
374
Modern China
3
HIST
375
Mod. India, Pakistan, Bangladesh
3
HIST
311
Early America
3
HIST
312
Civil War & Reconstruction
3
HIST
313
Gilded Age to 1940
3
HIST
320
US Since 1940
3
HIST
403
Gender in US & Canadian West
3
HIST
408
Gender in America
3
HIST
409
Japanese Women's History
3
HIST
412
Race & Class in America
3
HIST
413
Race in Latin America
3
HIST
Take One of the Following:
Take One of the Following:

419
Fam, Gndr, Law in Greece/Rome
3
HIST
425
Gender in Latin America
3
HIST
447
History of NA Indians
3
HIST
464
History of Yellowstone
3
HIST
467
Women in Asia
3

HIST
402
Trans Mississippi West
3
HIST
404
Montana & the West
3
HIST
406
Anti-Communism in T/E Era
3
HIST
410
Latin America Social History
3
HIST
422
History of the Amer Constitution
4
HIST
423
Protestant Reformation
3
HIST
426
The Renaissance
3
HIST
431
Sci, Tech, & Society: 1500-1800
3
HIST
432
Modern Science
3
HIST
455
History of American Technology
3
HIST
456
American Thought & Culture
3
HIST
457
Museum History
3
HIST
460
European Intellectual History
3
HIST
Take Two of the Following:

464
History of Yellowstone
3
HIST
465
Ecology & Nature in Japan
3
HIST
466
US Environmental History
3
HIST
468
Animal Histories
3
HIST
469
World Environmental History
3
Required:
HIST
401
Sem in Historical Methodology
3

Subject #
Course Title
Take One of the Following:
HDCF
150IS
Lifespan Human Dev
3
HDCF
160
Hum Dev: Conception to Adol
3
Secondary Professional Preparation
EDCI
102
In-School Experience
1
EDCI
209
Ed Psych & Adolescent Dev
3
EDCI
320
Found of Instr Computing
2
EDCI
360
Foundations of Assessment
2
HDHL
106
Drug/Health Issues for Educ
1
EDSD
363
Multicultural Education
1
EDSD
458
Meth of Teach Social Studies
3
HDCF
356
Exceptional Needs (0-21)
3
CR Grade Subject #
Course Title CR Grade

EDSD
301
Paraprofessional Experience
1
EDSD
410
Student Teaching (10-12 CR)
EDSD
413C
Professional Issues
2
MATH
ENGL 121W College
Writing I
3
COM* 110US Intro to
Public
Com
3
*May take approved courses with the letters US for
University Seminar Core.
For Office Use Only:
First Aid with CPR
Paraprofessional Experience
Disclosure Statement
_____________________________________________________________________________
Student's Signature
________________________________
Date

_____________________________________________________________________________
Advisor’s Signature
_____________________________________________________________________
Certification Officer's Signature
* Taking this course Spring Semester
** Taking this course Fall Semester or Summer Semester
________________________________
Date
____________________________
Date