1. !8157-PARA!
Virginia M. Barry, Ph.D.
Commissioner of Education
Tel. 603-271-3144
Paul Leather
Deputy Commissioner
Tel. 603-271-3801
STATE OF NEW HAMPSHIRE
DEPARTMENT OF EDUCATION
101 Pleasant Street
Concord, N.H. 03301
Tel: 603-271-2408
Fax: 603-271-4134
CONTACT:
BUREAU OF CREDENTIALING
101 PLEASANT STREET
CONCORD, NH 03301
TEL: 271-2409
PARAEDUCATOR CERTIFICATION APPLICATION, Ed 504.05
INSTRUCTIONS: Please print or type. Non-refundable processing fee of $25.00 is required with application. Make payable to the STATE OF NEW HAMPSHIRE. Penalty of $8.00 for returned checks (per RSA 6:11-a).
Paraeducator I: Submit with application form notarized copy of High School Diploma or GED, and successfully complete all competencies for Paraeducator I Assessment. Fee is $25.00, check made payable to State of New Hampshire.
Paraeducator II: Submit with application form official college transcripts. If coursework has not been completed, then the completed portfolio process or the completed assessment option needs to be submitted. Fee is $25.00, check made payable to State of New Hampshire.
PLEASE COMPLETE ALL INFORMATION.
All * Fields are REQUIRED:
1. *Social Security Number: __________ / ______ / __________
2. *Date of Birth: ________ / _________ / _________
3.* Name:_______________________________________________________________________________________________________________
Last Maiden First MI
4. *Address: _____________________________________________________________________________________________________________
Street Town State Zip
*Email address: _______________________________________ *Alternative email address: ___________________________________________
5. Sex: Male / Female 6. *Phone: ( ) ____________________________ 7. Date of Application: _______/_______/______
8.EDUCATIONAL INFORMATION:
HIGH SCHOOL: NOTARIZED COPY OF HS DIPLOMA OR GED.
STATE
CURRICULUM
DATE GRANTED
COLLEGE: OFFICIAL TRANSCRIPTS ARE REQUIRED.
STATE
DEGREE / MAJOR
Submit OFFICIAL college transcript / high school diploma: enclosed ___________ being sent under separate cover ___________
PLEASE CIRCLE APPROPRIATE ANSWERS
10. Have you ever held a New Hampshire certificate? YES NO
If yes, what year did it expire ___________ and under what name ____________________________________________
Enclose copies of any teaching certificates held in New Hampshire or other states.
11. Have you ever been convicted of a felony? Yes No IF YES, ATTACH EXPLANATION
12. Have you ever had a teaching credential revoked? Yes No IF YES, ATTACH EXPLANATION
13. Have you ever surrendered your teaching credential
in any other state or country? Yes No IF YES, ATTACH EXPLANATION
14. Are you currently being investigated in any other state? Yes No IF YES, ATTACH EXPLANATION
15. To be used for statistical purposes only: ______ American Indian _______ Asian/PAC _______ Black/Non Hispanic ______ White/Non Hispanic _______ Hispanic
____________________________________________________________________________ ___________________________
SIGNATURE OF APPLICANT DATE
Revised February 25, 2013 213 64 4831 10 11 1954
Jeffrey Heck Eileen T.
P O Box 1716 Conway NH 03818
etjeffrey@go.granite.edu
603 730 7494
09 23 2014
Granite State College
NH Associate General 9/2014
Granite State College NH B.S. Comm. Studies in progress
Eileen T. Jeffrey 9/23/2014