Catalog (Academic Year):

Date:

Name:

First

Last

Birthdate:

Student ID:

Email Address:

Ethnicity:

Cell Phone:

Alternate Phone:

Current Address:

Address Line 1

Address Line 2

City

State

Zip Code

Permanent Address: (If different from above)

Address Line 1

Address Line 2

City

State

Zip Code

Overall GPA:

List all Majors:

List all Minors:

Signature of Director of Field Experience: *

First

Last

Signature of Major Advisor: *

First

Last

Have you ever had adverse action taken against any professional certificate, license, or other credential issued for practice in any field, including teaching, or is any such action pending? (Adverse action includes, but is not limited to, letter or warning, reprimand, denial, suspension, revocation, voluntary surrender, cancellation or failure to renew.):

Yes
No

Have you ever resigned or been disciplined, discharged, or asked to resign or retire from a professional position or Military service because of allegations of misconduct, or is any such action pending? (The scope of this question includes being dismissed from any teaching, administrative or specialist position for failure or refusal to fulfill an employment contract or any other misconduct associated with the teaching profession.):

Yes
No

Have your ever been convicted of a felony or misdemeanor crime in Montana or any other state or country, or is any such action pending? You may omit minor traffic violations, such as speeding tickets, but you must include DWIs, DUIs, reckless driving or similar violations. You must include cases in which you were found guilty, entered into a plea agreement, or entered a plea of “no contest” (or similar plea). We encourage you to be as inclusive as possible. If you are uncertain about whether to include a particular experience, contact Montana Office of Public Instruction Legal Division at 406-444-4402:

Yes
No

If the answer to the question above is “Yes” please include the court name and address and the case name AND number if available. If you have copies of court documents, please provide copies with your statement regarding the circumstances:

Student Signature: *

First

Last

I certify that all the information above is accurate

TEP Confirmation of Background Check and Eligibility