The 21 Kansas Form is an application used by individuals seeking to upgrade to a professional license in the state of Kansas. This form collects essential information about the applicant, including personal details, educational background, and any prior legal issues that may affect licensure. Completing this form accurately is crucial for a smooth application process, so make sure to fill it out carefully by clicking the button below.
The 21 Kansas form, officially known as the Application for Kansas Upgrade to Professional License, serves as a crucial document for individuals seeking to advance their teaching credentials within the state. This form requires applicants to provide essential personal information, including their legal name, Social Security number, and contact details. Additionally, applicants must disclose their birthdate and gender. A significant section of the form addresses any prior criminal history, including felony convictions and disciplinary actions related to teaching licenses. Applicants are asked to provide documentation for any criminal convictions or disciplinary actions, ensuring transparency in their professional history. Furthermore, the form requests a comprehensive list of degrees earned, along with the institutions and years of graduation. The applicant must affirm their good moral character and the accuracy of the information provided. A processing fee of $54.00 is required, and applicants are instructed on acceptable payment methods. Lastly, the form includes a verification section for an induction and mentoring program, which is mandatory for conditionally or initially licensed educators. This verification must be completed by a district administrator and confirms the successful completion of a year-long mentoring experience, which is a prerequisite for receiving a professional license.
Completing the 21 Kansas form requires careful attention to detail. Each section must be filled out accurately to ensure a smooth application process for a professional license. Below are the steps to guide you through the completion of the form.
After submitting the form, it will be processed by the Kansas State Department of Education. Ensure that all required documents are attached to avoid delays in your application. Keep a copy of your application and payment for your records.
When filling out the 21 Kansas form, follow these guidelines:
Avoid these common mistakes:
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F O R M 21
Application for Kansas
Upgrade to
P R O F E S S I O N A L L I C E N S E
SECTION A – TO BE COMPLETED BY APPLICANT
1.
Social Security Number
___ ___ ___ - ___
___ - ___ ___
___ ___
2.
Legal Name
(First)
(Middle)
(Last)
3.
List all prior names (maiden, alias, previous married, etc.)
4.
Mailing Address
City
State
Zip Code
5.
Birthdate (MM/DD/YYYY)
6. Gender
7. Phone:
___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___
Male
Female
Alternate Phone:
8. a. Have you ever been convicted of a felony?
NO
YES
If yes, please attach a copy of the court documents regarding conviction.
b.Have you ever been convicted of ANY crime involving theft, drugs, or a child?
c.Have you entered into a criminal diversion agreement after being charged with any offense described in question 8a or 8b?
If yes, please attach a copy of the diversion agreement.
d.Are criminal charges pending against you in any state involving any of the offenses described in question 8a or 8b?
If yes, please attach a copy of the court documents regarding your case.
e.Have you had a teacher’s or school administrator’s certificate or license denied, suspended, revoked or been the subject of other disciplinary action in any state?
If yes, please indicate the action taken:
denied,
suspended or
revoked.
Which state(s)?
Please attach a copy of the documents regarding the official action taken.
f.Is disciplinary action pending against you in any state regarding a teacher’s or administrator’s certificate or license?
If yes, please attach a copy of the official documents regarding the action pending against you.
g.Have you ever been disbarred or had a professional license or state issued certificate denied, suspended, revoked or been the subject of other disciplinary action regarding any profession in Kansas or any other state?
h.Have you ever been terminated, suspended, or otherwise disciplined by a local Board of Education for falsifying or altering student tests or student test scores?
If yes, which district(s)?
When?
i.Have you ever falsified or altered assessment data, documents, or test score reports required for licensure?
YES If yes, what state(s)?
9. List all degrees earned: (example: BA, MS, EDS, etc.) If you earned a new degree since your initial license, attach official transcripts.
Institution:_________________ Degree:__________ Year Earned:________
10.I certify that I am of good moral character and that the information on this application is true and complete to the best of my knowledge. I understand that any misrepresentation of facts may result in the denial or revocation of my license.
Signature of Applicant
Date
Include a $54.00 Application Fee made payable to the Kansas State Department of Education.
Money order or cashier’s check preferred. Personal checks accepted.
DO NOT SEND CASH.
MAIL TO: Teacher Education and Licensure, KSDE, 120 SE 10th Avenue, Topeka, KS 66612-1182.
Processing fee CANNOT be refunded and does not guarantee a license will be issued.
Form 21 – Professional License
1
Revised 03-12
VERIFICATION OF AN INDUCTION AND MENTORING PROGRAM
Each conditionally or initially licensed teacher, school specialist or school leader must complete a year-long, district- administered induction and mentoring program to pass the performance assessment as a prerequisite to receiving a professional license.
Mentored Teacher/School Specialist/School Leader information
This form should be completed by the district or building administrator where the mentoring program occurred.
Name (First)
Social Security Number ___
___ ___ - ___
___ - ___ ___ ___ ___
OR
Teacher identification number from license
_______________________________________
If the current school year is the mentor year, do not complete and submit until after May 15th
I verify:
The above named applicant successfully completed a year-long induction and mentoring program provided by the district. (By verifying this information, a professional license will be issued upon fulfillment of all other regulatory requirements.)
District Name and Number where mentoring occurred
Accreditation Information
NO YES
State Accredited School?
If not state accredited, attach verification of accreditation status.
Building Name
Beginning Date of mentored
Ending date of mentored
Assignment of teacher/school specialist/leader
Grade level
experience (MM/DD/YYYY)
during mentored experience
Administrator’s Name (Please Print or Type)
Administrator’s Position
(May be district or building)
School Phone Number
Administrator’s Signature
Who was the mentor?
_______________________________________________________
_________________________________
Mentor’s Name:
Mentor’s SS# or teacher ID#
2
3
This form is also for those upgrading their licenses. It applies to both new and existing license holders.
The application fee of $54.00 is mandatory. Applications will not be processed without it.
While money orders or cashier’s checks are preferred, personal checks are indeed accepted.
Cash should never be sent. Only checks or money orders are acceptable.
You only need to list prior names that are relevant to your application, such as maiden names or aliases.
If you answer "yes" to any criminal history questions, you must attach relevant court documents.
Completing a year-long induction and mentoring program is a requirement for obtaining a professional license.
If the current school year is your mentor year, wait until after May 15th to submit the form.
The processing fee is non-refundable, regardless of whether your application is approved or denied.
By signing the form, you certify that you are of good moral character. Misrepresentation can lead to denial or revocation of your license.
The 21 Kansas form is a crucial document for individuals seeking an upgrade to a professional license in Kansas. Alongside this form, several other documents are commonly required to ensure that applicants meet all necessary criteria. Below is a list of these accompanying forms and documents, each serving a specific purpose in the licensing process.
Each of these documents plays a vital role in the application process for a professional license in Kansas. Ensuring that all necessary forms are completed and submitted can significantly enhance the likelihood of a successful application. Proper preparation and attention to detail are essential for navigating this important milestone in one’s professional career.