2016 Application
Mississippi Alternate Path to Quality Teachers Program
*June 6-24, 2016
Thank you for your inquiry regarding the Mississippi Alternate Path to Quality Teachers Training Institute. To
apply for the Institute, please return all required documents as a complete packet no later than April 15, 2016, to
the:
Mississippi Community College Foundation
ATTN: Lauren Stewart
1900 Lakeland Drive, Box 941
Jackson, MS 39216
(601) 321-3902
mapqt@mccfms.org
Directions: Please read carefully and submit this checklist with your application packet. Application deadline is
April 15, 2016.
Mark the boxes to indicate you have enclosed the required items.
1. Complete Packet - Return the signed application to this office with all required documents as a
single, complete packet.
2. College Transcripts - College transcripts from all institutions must be submitted in a sealed envelope
bearing the seal or signature of the registrar. Have the institution mail transcripts to you and include in
your packet stamped student issued.” Do not open the sealed envelopes! We can also accept E-SCRIP,
which is an electronic copy of your transcript. Our school code is #1483. If you plan to send your
transcript via e-script, please indicate here.____________________________________________
3. Official Core and Praxis II Test Scores - All Core and Praxis II scores can be sent electronically. Our
school code is #1483.
4. ACT - If you scored a 21 or higher on the ACT (with subscores 18 or higher), you DO NOT need to
take the Core Test. Contact the ACT testing center at 319-337-1313 to request your copy or go to
www.ACTstudent.org
(original ACT score sheets will be returned to you)
5. Please complete the Pre-Core Worksheet and send it in with your packet. It can be found on our
Website.
6. $50.00 - Non-refundable Application Fee (payment method - money order or cashier’s check
made payable to MCCF/MAPQT.) *If accepted, the $50 application fee will be applied to your
summer tuition fee.
**MDE will also need sealed copies of your transcripts so you may want to order two copies.
Completion of this application does not guarantee acceptance into the Mississippi Alternate Path to Quality
Teachers Training Institute. Our office will notify you in writing of your acceptance or rejection no later than
May 15, 2016. Summer session tuition fee is *$1600 and is due by May 15, 2016. Tuition fee is non-refundable
after June 6, 2016. *The three-week summer session will be held Monday–Friday, June 6-24, 2016, 8:00 a.m.–
3:30 p.m. daily. Payment method should be in the form of a money order or cashier’s check.
mapqt@mccfms.org
Mississippi Alternate Path to Quality Teachers Training Institute Application
Must be completed and submitted with all required documents. (Type or print in black ink only)
1.Name:___________________________________________________________________________________
Last
First
Middle
Maiden
2. Social Security Number: ___________-_________-___________
3 Address _________________________________________________________________________________
Number & Street
City
State
Zip
4. Phone: Home: (____) ________________________/Cell: (____) __________________________________
Email: ___________________________________________________
What is the best method of contact? E-mail ___ text ___ phone ___
5. Birth Date: ____/_____/______ Gender: ______ (F=Female, M=Male)
6. Ethnicity: Please place a check mark by the applicable category
□ American Indian
□ Alaskan Native
□ Asian
□ White-non-Hispanic □ Hispanic
□ Pacific Islander
□ Black-non-Hispanic
□ other
(*Note: Ethnicity information is used for statistical purposes and to provide information required by the U.S. Department of Education in accordance with applicable
federal regulations. Your cooperation in providing this information is appreciated.)
7.In what subject area did you take Praxis II? ___________________________________________________
8. In what year did you earn your degree? ________________________ Institution:______________________
9. Please check the site you wish to attend. If the site you chose fails to make or the site fills up, you will be
offered an alternate site.
___ Belden, Itawamba
____ Philadelphia, East Central Community College
___ Gautier, MS Gulf Coast Community College
____ Senatobia, Northwest MS Community College
___ Raymond, Hinds Community College
____ Indianola, MS Delta Community College
___ Hattiesburg, Pearl River Community College
Office Use Only
_____ Check Character Determination
10. CHARACTER DETERMINATION (Check YES or NO to the left of each question)
____ Yes ____ No Are you currently addicted or currently dependent on alcohol?
____ Yes ____ No Are you currently addicted or currently dependent on other habit-forming drug?.
_____Yes____ No Are you a habitual user of narcotics, barbiturates, amphetamines, hallucinogens, or other drugs having similar
effects?
____ Yes ____ No Have you been convicted, pled guilty, or entered a plea of nolo contendere to a felony as defined by federal or
state law?
____ Yes ____ No Have you been convicted, pled guilty, entered a plea of nolo contendere to a sex offense as defined by federal or
state law?
_____Yes ____ No Have you had a teaching certificate/license denied, suspended, and/or revoked by another state?
I understand that a "Yes" answer on any of the above questions will require a hearing before the Commission on Teacher and
Administrator Education, Certification and Licensure and Development when I submit my application for a license and could result in
a denial of a license. I acknowledge that the answers to the above questions are true and correct.
Signature of Applicant _________________________Date__________________________