NCELP

New Century Educational Leadership
Program
Application For Admission

Please type in your information in the spaces provided, and press the Submit button to submit your application to the NCELP office. In many instances it is necessary only to check the correct response; however, provide all the information requested. If you need assistance with the completion of this application, please contact the NCELP office at (254) 968-9805.

Personal Information

Name (Last, First, Middle, Maiden):
Address (Home): City:
State: Zip: Date Of Birth: Sex: Male Female
Phone (Home): (Work) Email:
Languages that you speak proficiently: English Spanish Other
Are you a citizen of the United States? Yes No

Certification

Indicate your current certificate status:

	Valid Texas Certificate	Date Issued:	Date Expires:
	Texas Emergency/Special Assignment Permit	Date Issued:	Date Expires:
	School District where employed:
	Valid Out of State Certificate	Date Issued:	Date Expires:
	State:
Do you possess a certificate which is currently suspended, revoked, or pending such action in any state?
	Yes No
	If yes, explain:

Education History

List all Colleges/Universities attended in chronological order:

Institution	Dates Attended	Degree	Major / Minor	Overall GPA *

* An official copy of all transcripts must be on file at Tarleton before full admission can be granted. Unoffical copies may be sent to the NCELP office with the application for initial processing.

Have you taken the Graduate Record Exam (GRE)?* Yes No
If yes, date test was taken: If No, when will test be taken?

* The TASP and GRE tests are entry requirements into the NCELP program and must be completed before full admission can be granted and prior to beginning the internship. It is not necessary to have completed the test before submitting the provided on a seperate sheet in the application packet. Current certified Texas Public School Teachers are exempt from the TASP requirement.

List leadership /management training experiences (if additional space is needed, please use the provided space at the end of the application):

Institution / Organization	Training Description	Dates Attended

Professional and Personal References

Please list three (3) persons whom we may contact for a reference. (One reference must be from a practicing superintendent.). If additional space is needed, please use provided space at the end of the application.

Name	Mailing Address City, State, Zip	Phone Numbers (Buisness and Home)	Title / Relationship

Work Experience

Please list information relating to your last five (5) years fo full-time work experience. Begin with your most recent experience. Work supervisors will be contacted for references. All responses will remain confidential. (If additional space is needed, please use the provided space at the end of the application.)

Dates	School Dist. / Firm Name Address	Phone Number	Position Applicant Held	Immediate Supervisor	Description of Duties

Writing Sample

Describe the characteristics of a principal in the role of an instructional leader.

Leadership Experience

You must document at least three years in a position with leadership responsibilities, 2 years of teaching experience, and a Bachelor's or Master's degree. Examples of leadership responsibilities include, but are not limited to: department chair, grade level chair, member of site-based decision making team or similar responsibilities. (If more space is needed, please use the additional space at the end of the application.)

Number of years with leadership responsibilities	Position Held	School District Name	Description of Leadership Responsibility

By signing this application:

*You are affirming that the contents of this application are true and correct to the best of your knowledge.

*You also acknowledge you must meet both the Finalist screening requirements for admission to the NCELP program and the screening requirements for employment at the sponsoring district in which you serve your internship before acceptance into the program.

Signature (by checking this box you are signing the application):
Date:

How did you find out about NCELP?

	Friend
	School
	Regional Service Center
	Newspaper
	Other