Teacher Preparation Program
(903) 223-3044

Alternative Certification Intern Information Form

Please complete upon securing employment.

Contact Information
  Last Name:      
  First Name:      
  Last 4 digits of SSN:      
  Mailing Address:      
  Zip Code:      
  Home Phone Number:      
  Cell Phone Number:      
  Email Address - Home:      
  Email Address - District:      
  Teaching Area Subject:      
  Teaching Area Grade Level:      

Employing District Information
  Employing District:      
  School Phone Number:      
  Superintendent Name:      
  Principal Name:      

Cooperating Teacher (Mentor) Information
  Mentor Teacher's Name:      
  Has Mentor Teacher completed the    
Cooperating Teacher Information    
 Yes   No 

New Intern Checklist
  Have you done the following?

  Provided copy of ISD contract to    
Education Office?    
 Yes   No 
  Provided Statement of Eligibility    
completed by your ISD to    
Education Office?:    
 Yes   No 
  Have you enrolled in    
ED 485 Internship class?    
 Yes   No 
  Made plans to attend    
mandatory orientation?    
 Yes   No 
  Applied for your    
Probationary Certificate?    
 Yes   No 
  Started Fingerprinting Process?      Yes   No 
  There is a $500 per semester supervision fee that will be charged to your
student account.
      Have you made payment  
arrangements through the  
university(Business Office and/or  
Financial Aid Office)  
 Yes   No 

State law requires that you be informed of the following: (1) you are entitled to request to be informed about the information about yourself collected by use of this form (with a few exceptions as provided by law); (2) you are entitled to receive and review that information; and (3) you are entitled to have the information corrected at no charge to you. For more information see our Privacy Statement.