Alternative Certification Initiative
Department of Educational Leadership
Western Illinois University
Application for Admission

Note:

While you are filling out this form, please do not use the "return" button on your keyboard. Please navigate through the form either by using the mouse or the "tab" button on your keyboard.
Name:
Address:
Home Phone:
Work Phone:
Email:

Education - List most recent degrees and/or additional hours first

YearInstution/major

Work Experience - List most recent position first and be sure to explain any gaps in employment.

Year(s)PostitonEmployer

List the name, address and phone number of three professional references who can attest to your work/administrative experience.

Name/PositionAddressPhone

List the name, address and phone number of two personal references who can attest to your character and personal qualities.

Name/PositionAddressPhone
What certifications or credentials do you currently hold? (CPA, RN, CLU, School Principal, etc.)
Date of basic skills test:
What professional or work-related awards or recognitions have you received in the past five years.
To what professional organizations do you currently hold membership?
What leadership positions have you held in organizations (e.g. service, religious, civic, professional)?
Acceptance in the program requires that candidates have a minimum of five years of management experience. For each management position, briefly describe your responsibilities within the organization and the supervisory duties you performed.
How would you describe your management style?
In your opinion, what are the top five attributes of an effective chief executive officer?
What is/are your personal goal(s) for the next five years?
What has been your involvement with the public schools in the past five years (professional or volunteer)? )
What do you think is the role of the superintendent and the board of education?
I understand that I am required to provide my own transportation to and from field experience and internship assignments. I attest that when using my personal auto, I am covered by valid auto insurance that provides at least the limits of coverage statutorily required to legally operate my vehicle in Illinois and all other jurisdictions in which I travel.
  I have read and understand the statement above.
To complete the application process, candidates must submit a check, within 10 days, in the amount of $50 to cover the evaluation/processing costs. Check should be made payable to:
Alternative Certification Initiative

and mailed to

Department of Educational Leadership
Western Illinois University
81 Horrabin Hall
Macomb, IL 61455
   
© 2011