Stephen F. Austin State University
Educator Certification
P. O. Box 6103 Nacogdoches, TX 75962-6103
Phone (936) 468-1607 Fax (936) 468-7356
VI PROBATIONARY CERTIFICATE APPLICATION
Today’s Date:
Applicant’s Social Security Number:
Applicant’s Last Name:
First Name:
Middle/Initial:
Previous: (If Applicable)
Applicant’s Address:
City:
State:
Zip:
Applicant’s Home Phone:
Wk/Cell Phone:
Home Email:
Work Email:
(MM/DD/YY) Bachelor’s Degree Conferred:
Name of University:
As a VI applicant, I agree to register for the SPE 558 practicum course, for each semester I am employed in an VI position if
not enrolled in SPE Master courses, not to exceed 3 years.. I understand that failure to register and pay fees in a timely
manner may result in an automatic drop from the course. I understand that I must submit the Probationary Certificate
forms to SFA and access the State Board for Educator Certification (SBEC) website www.sbec.state.tx.us and apply for a
probationary certificate. I agree to comply with the written local school board policies, state regulations, and applicable state
and federal laws. I have reviewed this application and I affirm that all of the information which I have completed on the
application is true.
Applicant’s Signature:
Date:
Mentor Agreement
I agree to serve as mentor for this intern. My signature indicates that I have read and understand this agreement.
Assigned Mentor’s Signature:
Date:
School District Name:
First Day of Instruction Duties:
School District Address /PO Box or Street Number
City/State/Zip Code
Name of School Bldg/Campus
Campus Phone #
Position Held/Grade Level
District Official’s Agreement
I approve the employment of the individual indicated above for a VI teaching position in our school district. I understand
that the Probationary certificate term is one year and may be extended for an additional two years on a yearly basis for a
maximum total of three years, if the applicant meets approval conditions. I understand that he/she must register for the SPE
558.
ISD Approval Signature/Title:
Date:
FOR OFFICE USE ONLY
Degree:
Date:
Name of Institution:
ISD:
ISD Employment Position
ISD Emp Start Dt:
Dept Approval Given By:
Tot CYS:
to
yr
Probationary Certificate:
1st
2nd
3rd
Dt 2 CYS Comp:
Dt Enrolled SFA Prog:
Revised 8/04/2008
SPE Courses Comp: SPE: 516,517,515,518,551,552,558
Substitution of Cswk:
Appr By:
Course Comp Dt: