Outline
The 21 Kansas form serves as a crucial application for individuals seeking to upgrade to a professional license in the education sector. This form collects essential information from applicants, including personal details such as legal name, mailing address, and social security number. It also requires applicants to disclose any prior names and to provide their birthdate and gender. A significant part of the application involves questions about the applicant's criminal history, including any felony convictions or disciplinary actions related to teaching credentials. Applicants must indicate whether they have faced any legal issues that could impact their eligibility for a professional license. Furthermore, the form requests a detailed account of educational qualifications, requiring applicants to list all degrees earned and to submit official transcripts for any new degrees obtained since their initial license. A certification statement at the end of the application ensures that the information provided is accurate and complete. To process the application, a fee of $54.00 must accompany the form, which can be paid via money order, cashier’s check, or personal check. Additionally, verification of completion of a year-long induction and mentoring program is necessary for those on a conditional or initial license, ensuring that all candidates meet the required standards before receiving their professional license.
Sample - 21 Kansas Form
Form 21 – Professional License Revised 03-12
1
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
Male
Female
7. Phone: ___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___
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?
NO YES If yes, please attach a copy of the court documents regarding conviction.
c. Have you entered into a criminal diversion agreement after being charged with any offense described in question 8a or 8b?
NO YES 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?
NO YES 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?
NO YES 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?
NO YES 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?
NO YES 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.
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?
NO YES If yes, which district(s)? When?
i. Have you ever falsified or altered assessment data, documents, or test score reports required for licensure?
NO YES If yes, what state(s)? When?
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:________
Institution:_________________ Degree:__________ Year Earned:________
Institution:_________________ Degree:__________ Year Earned:________
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 10
th
Avenue, Topeka, KS 66612-1182.
Processing fee CANNOT be refunded and does not guarantee a license will be issued.
Form 21 – Professional License Revised 03-12
2
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) (Middle) (Last)
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 15
th
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
State Accredited School? NO YES
If not state accredited, attach verification of accreditation status.
Building Name
Beginning Date of mentored
experience (MM/DD/YYYY)
Ending date of mentored
experience (MM/DD/YYYY)
Assignment of teacher/school specialist/leader
during mentored experience
Grade level
Administrator’s Name (Please Print or
Type)
Administrator’s Position
(May be district or building)
School Phone Number
Administrator’s Signature
Date
Who was the mentor?
_______________________________________________________ _________________________________
Mentor’s Name: Mentor’s SS# or teacher ID#
Form 21 – Professional License Revised 03-12
3
Form Information
| Fact Name | Fact Description |
|---|---|
| Purpose of Form | The 21 Kansas Form is an application for upgrading to a professional teaching license in Kansas. |
| Applicant Requirements | Applicants must provide personal information, including their Social Security Number, legal name, and details about any criminal history. |
| Verification Process | Completion of a year-long induction and mentoring program is required for conditional or initial license holders to qualify for a professional license. |
| Governing Laws | This form is governed by the Kansas Statutes Annotated (KSA) § 72-1430, which outlines the licensing requirements for educators. |
Detailed Guide for Filling Out 21 Kansas
After gathering all necessary information, proceed to fill out the 21 Kansas form accurately. Ensure all details are complete and correct before submission.
- Provide your Social Security Number in the designated format.
- Enter your legal name, including first, middle, and last names.
- List any prior names you have used, such as maiden names or aliases.
- Fill in your mailing address, including city, state, and zip code.
- Input your birthdate in the format MM/DD/YYYY.
- Select your gender by marking either Male or Female.
- Provide your primary phone number and, if applicable, an alternate phone number.
- Answer questions 8a through 8i regarding any criminal history or disciplinary actions. Attach required documents for any "YES" responses.
- List all degrees you have earned, including the institution, degree type, and year earned. Attach official transcripts for any new degrees.
- Sign and date the application to certify that the information provided is accurate and complete.
- Include a $54.00 application fee, payable to the Kansas State Department of Education. Use a money order or cashier’s check when possible. Do not send cash.
- Mail the completed form and payment to: Teacher Education and Licensure, KSDE, 120 SE 10th Avenue, Topeka, KS 66612-1182.
Obtain Answers on 21 Kansas
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What is the 21 Kansas form?
The 21 Kansas form, officially known as the Application for Kansas Upgrade to Professional License, is a document that educators must complete to upgrade their teaching credentials 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 impact their licensing status.
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Who needs to complete this form?
This form is intended for teachers, school specialists, and school leaders who are seeking to upgrade their licenses to a professional level. If you have been conditionally or initially licensed and have completed the required induction and mentoring program, this application is for you.
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What information is required on the form?
Applicants must provide a variety of information, including:
- Social Security Number
- Legal name and any prior names
- Contact information, including mailing address and phone numbers
- Date of birth and gender
- Details regarding any criminal history or disciplinary actions
- Educational degrees earned and institutions attended
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What should I do if I have a criminal history?
If you have been convicted of a felony or any crime involving theft, drugs, or a child, you must disclose this information on the form. Additionally, you are required to attach relevant court documents. Transparency is crucial, as failure to disclose this information could lead to denial or revocation of your license.
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How much does it cost to submit the application?
The application fee is $54.00. Payments should be made to the Kansas State Department of Education. Accepted payment methods include money orders, cashier’s checks, and personal checks. It is important to note that cash should not be sent, and the processing fee is non-refundable.
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What happens after I submit my application?
Once your application is submitted, it will be processed by the Kansas State Department of Education. Keep in mind that submitting the application and fee does not guarantee that a license will be issued. The processing fee is non-refundable, regardless of the outcome.
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What is the induction and mentoring program?
The induction and mentoring program is a year-long program that newly licensed educators must complete as part of their professional development. This program is designed to support new teachers through mentorship and guidance, helping them transition into their roles effectively.
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Who verifies the completion of the induction program?
A district or building administrator is responsible for verifying the completion of the induction and mentoring program. This verification is necessary for the issuance of a professional license and must be included with the application.
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Where do I send my completed application?
Your completed application, along with the payment and any required documents, should be mailed to:
Teacher Education and Licensure
Kansas State Department of Education
120 SE 10th Avenue
Topeka, KS 66612-1182
Common mistakes
Filling out the 21 Kansas form can be a straightforward process, but many applicants make common mistakes that can delay their application. One frequent error is leaving out critical personal information. For example, applicants often forget to include their Social Security Number or provide an incomplete mailing address. This information is essential for processing the application and should be double-checked before submission.
Another mistake involves the failure to disclose prior names. Many applicants overlook the section that asks for maiden names, aliases, or previous married names. Omitting this information can lead to complications in verifying an applicant’s history, which may result in delays or even denial of the license.
Additionally, applicants sometimes misinterpret the criminal history questions. Some may answer "no" to questions about felony convictions or other criminal actions when they should disclose relevant information. It is crucial to answer these questions honestly and provide any necessary documentation. Failing to do so could be seen as misrepresentation, jeopardizing the application.
Inaccurate or incomplete educational information is another common pitfall. Applicants may forget to list all degrees earned or fail to attach official transcripts for newly earned degrees. This oversight can hinder the evaluation of qualifications and may lead to a denial of the license.
Finally, many applicants neglect to sign and date the form. This step may seem minor, but without a signature, the application is considered incomplete. It is essential to review the entire form before submission to ensure that all required fields are filled out correctly and that the application is signed and dated.
Documents used along the form
The 21 Kansas form is an essential document for individuals seeking to upgrade to a professional teaching license in Kansas. Along with this form, several other documents are typically required to support the application process. Below is a list of four commonly used forms and documents that complement the 21 Kansas form, each serving a specific purpose in the licensing procedure.
- Verification of Induction and Mentoring Program: This form confirms that the applicant has completed a year-long induction and mentoring program, which is a prerequisite for receiving a professional license. It must be filled out by the district or building administrator overseeing the mentoring process.
- Official Transcripts: Applicants must provide official transcripts from all educational institutions attended. These transcripts verify the degrees earned and are crucial for demonstrating educational qualifications necessary for licensure.
- Criminal Background Check Documentation: If the applicant has a criminal history, relevant court documents must be attached. This includes any felony convictions or charges pending that could impact the licensing decision.
- Disciplinary Action Records: If applicable, documents detailing any previous disciplinary actions taken against the applicant’s teaching or professional licenses must be submitted. This includes records of suspensions, revocations, or denials from any state.
Each of these documents plays a vital role in ensuring that the application for a professional license is complete and meets all regulatory requirements. Properly compiling and submitting these forms will facilitate a smoother licensing process.
Similar forms
The 21 Kansas form is similar to several other documents used in professional licensing and certification processes. Below is a list of nine documents that share similarities with the 21 Kansas form, highlighting their common features.
- Application for Teacher Certification - Like the 21 Kansas form, this application requires personal information, educational background, and disclosures related to criminal history and professional conduct.
- Professional License Application - This document also requests details about the applicant's qualifications, background checks, and any prior disciplinary actions similar to those found in the Kansas form.
- Background Check Authorization Form - Both forms necessitate the disclosure of criminal history and require applicants to authorize background checks, ensuring a thorough vetting process.
- Continuing Education Verification Form - This form, like the 21 Kansas form, includes sections for documenting educational achievements and professional development, which are critical for maintaining licensure.
- Application for State Certification Renewal - Similar to the 21 Kansas form, this renewal application requires verification of continued compliance with professional standards and may include updates on any disciplinary actions.
- Teacher Evaluation Form - This document assesses an educator's performance, much like how the Kansas form evaluates the qualifications and character of the applicant.
- Induction Program Completion Form - Both forms require verification of program completion, emphasizing the importance of mentorship and ongoing support in professional development.
- Request for Transcript Form - This form is used to obtain official transcripts, which are also necessary for the 21 Kansas form to verify educational qualifications.
- Professional Conduct Disclosure Form - Similar to the Kansas form, this document requires applicants to disclose any past misconduct or disciplinary actions, ensuring transparency in the licensing process.
Dos and Don'ts
When filling out the 21 Kansas form, it's essential to follow specific guidelines to ensure accuracy and compliance. Here are five things you should and shouldn't do:
- Do provide your Social Security Number accurately.
- Do list all prior names, including maiden names and aliases.
- Do attach required court documents if you answer "yes" to any conviction-related questions.
- Do ensure that all information is complete and truthful to avoid potential denial of your application.
- Do include the application fee, making sure it is not cash.
- Don't leave any sections blank; incomplete forms may delay processing.
- Don't submit personal checks without confirming they are accepted.
- Don't forget to sign and date the application; an unsigned form is invalid.
- Don't ignore the requirement to attach official transcripts for any new degrees earned.
- Don't send the application without reviewing it for accuracy.
Misconceptions
Misconceptions about the 21 Kansas form can lead to confusion and mistakes in the application process. Here are five common misconceptions explained:
- Misconception 1: The application fee is refundable.
- Misconception 2: Only felony convictions need to be reported.
- Misconception 3: The form does not require disclosure of disciplinary actions from other states.
- Misconception 4: Completing the induction program guarantees a professional license.
- Misconception 5: Personal checks are the only acceptable payment method.
Many believe that the $54.00 application fee can be refunded if the license is not granted. In reality, the processing fee is non-refundable, regardless of the outcome of the application.
Some applicants think they only need to disclose felony convictions. However, any crime involving theft, drugs, or a child must also be reported, regardless of whether it is a felony or misdemeanor.
Applicants often overlook the requirement to disclose any disciplinary actions taken against their teaching credentials in any state. This information is crucial for the review process.
While completing a year-long induction and mentoring program is necessary, it does not automatically guarantee a professional license. All other regulatory requirements must also be fulfilled.
Some applicants assume that only personal checks can be used for the application fee. In fact, money orders and cashier’s checks are preferred, while personal checks are also accepted. Cash should never be sent.
Key takeaways
The 21 Kansas form is essential for individuals seeking to upgrade to a professional license in Kansas.
Applicants must provide personal information, including their Social Security Number, legal name, and contact details.
Questions regarding criminal history are included, and applicants must disclose any felony convictions or pending charges.
It is important to attach relevant court documents if any criminal history applies to the applicant.
Applicants need to certify their good moral character, affirming that the information provided is accurate.
A processing fee of $54.00 must accompany the application, payable to the Kansas State Department of Education.