TEXAS A&M UNIVERSITY-TEXARKANA
Teacher Preparation Program
(903) 223-3044

Graduate Initial Teacher Certification Intern Information Form

Please complete upon securing employment.

Contact Information
     
  Last Name:      
  First Name:      
  Last 4 digits of SSN:      
  Mailing Address:      
  City:      
  State:      
  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:      
  Campus:      
  School Phone Number:      
  Superintendent Name:      
  Principal Name:      
     

Cooperating Teacher (Mentor) Information
     
  Mentor Teacher's Name:      
     
  Has Mentor Teacher completed the    
Cooperating Teacher Information    
Sheet?:    
 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 585 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.
 
    
  Choose one of below:

    1)  Do you prefer to make payment  
arrangements through the  
university(Business Office and/or  
Financial Aid Office)  
 Yes   No 
    
      2)  payroll deduct (two payments  
of $250) through your ISD?  
 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.