English as a Second Language Statement
Student Name:
U of M ID number:
U of M Email:
Phone Number:
Licensure area (s):
CEHD Licensure Officer:
I am requesting that you supply with me a letter, verifying that English is not my primary language, in order
to qualify for an extension of testing time with MTLE (Minnesota Teacher Licensure Examinations).
I hereby testify that English is my second language, and my primary/native language
is___________________________________________.
I understand that any misrepresentation of my language status on my part will result in disqualification of
my MTLE test scores.
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________________________________________________________
________________________________________
Signature of Student
Date
Return this form to:
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Teacher Licensure Officer
College of Education and Human Development
275 Peik Hall, 159 Pillsbury Drive
Minneapolis, MN 55455
Email: asai0003@umn.edu
Fax: 612-626-6765