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Application

Impact ETX

Please complete this application to be considered for acceptance into the Region 7 Alternative Certification Program, IMPACT ETX.

Before starting the application, please note that you'll need to upload a resume. It's recommended to have it ready before completing the form, as the session may time out if inactive.

Fields marked with an * are required and must be completed before submitting the form.

Contact Information

First Name*

Answer Required

Middle Name*

Answer Required

Last Name*

Answer Required

Maiden/Former Name

Answer Required

Street Address*

Answer Required

City*

Answer Required

State*

Answer Required

Zip/Postal*

Answer Required

Last 4 Digits of Social Security Number*

Answer Required

Email Address*

Answer Required

Primary Phone*

Number Required

Alternate Phone

Number Required

Are you legally able to work in the U.S.?*

Answer Required

Yes

How did you hear about us?*

Answer Required

Contact Information

Choose your certification area of interest:*

Answer Required

College/University Information

Applicatiosn will only be processed with ALL college transcripts, GPA, and course hour requirements OR a passing PACT score and three references. Meeting application requirements does not guarantee acceptance into the IMPACT ETX program.

Candidates with a degree from a foreign institution MUST have transcripts evaluated by a foreign credentials evaluation service recognized by TEA showing degree earned and grade equivalencies Foreign Credentials Services. AND take the TOEFL (Test of English as a Foreign Language), scoring a minimum of 22 in listening / 24 in speaking / 21 in writing. For more information and links to resources, see our Foreign Degree page.

Type of School*

Answer Required

Name of School*

Answer Required

City*

Answer Required

State*

Answer Required

Attended From (mm/yyyy)*

Answer Required

Attended To (mm/yyyy)*

Answer Required

Graduation Date (mm/yyyy)*

Answer Required

Degree*

Answer Required

Subject*

Answer Required

GPA*

Answer Required

Additional College/University Information

Type of School

Answer Required

Name of School

Answer Required

City

Answer Required

State

Answer Required

Attended From (mm/yyyy)

Answer Required

Attended To (mm/yyyy)

Answer Required

Graduation Date (mm/yyyy)

Answer Required

Degree

Answer Required

Subject

Answer Required

Additional College/University Information

Type of School

Answer Required

Name of School

Answer Required

City

Answer Required

State

Answer Required

Attended From (mm/yyyy)

Answer Required

Attended To (mm/yyyy)

Answer Required

Graduation Date (mm/yyyy)

Answer Required

Degree

Answer Required

Subject

Answer Required

Transcript Acknowledgement

We require transcripts from ALL colleges/universities you have attended. Typically, there are two ways to request an official transcript: PDF electronic transcripts or print/mailed transcripts. Because the printed/mailed option takes longer, we encourage using certified electronic (digital) transcripts if available. Certified electronic (digital) transcripts can be directed to [email protected].

I understand that a completed application must include transcripts from ALL colleges and universities attended. I have chosen to submit the transcripts via:*

Answer Required

PDF electronic transcript

Print/Mailed transcript

Educational Background

Pact TExES Information: If you do not have a minimum of required hours of coursework in the area where you will be seeking certification as posted on our website, you will be required to pass the Pre-Admission Content Test (PACT).

If applicable, complete the information below concerning your PACT TExES test. You must attach a copy of the scores.

TEA ID # (if applicable)

Answer Required

Content Area/Date of Test/Score

Answer Required

PACT TExES Scores

Answer Required

Choose a file or drag it here.

Teaching Experience

Have you previously been accepted to a teacher preparation program?*

Answer Required

Yes

If yes, when and where?

Answer Required

Are you a certified teacher?*

Answer Required

Yes

Have you ever taught in a Texas public school?*

Answer Required

Yes

If yes, when and where?

Answer Required

Do you have a potential job offer to be a classroom teacher from a school district in the Region 7 area?*

Answer Required

Yes

If yes, where?

Answer Required

Are you, or have you ever been an Education Aide or served as a long-term sub in Texas?*

Answer Required

Yes

If yes, when and where?

Answer Required

Why do you want to be a teacher in the Region 7 area? Please include your goals and aspirations for teaching.*

Answer Required

Please upload your resume.*

Answer Required

Choose a file or drag it here.

Background Information

Have you ever been convicted of a violation of law other than a minor traffic violation?*

Answer Required

Yes

If yes, please explain.

Answer Required

Have you been convicted of any offense for physical or sexual abuse of a child?*

Answer Required

Yes

If yes, please explain.

Answer Required

Have you ever had a charge of child abuse against you substantiated?*

Answer Required

Yes

If yes, please explain.

Answer Required

Have you ever had a professional certificate revoked or suspended?*

Answer Required

Yes

If yes, please explain.

Answer Required

Have you ever been involuntarily terminated or asked to resign, or resigned in lieu of termination from the employment of another school district?*

Answer Required

Yes

If yes, please give the name of the district, the date, and the reason for the resignation or termination.

Answer Required

Consent to Perform Criminal History / Background Check

You MUST pass a criminal history background check to be admitted into the education preparation program. Conviction of a crime is not an automatic bar to admission. Be aware that conviction of an offense may affect your eligibility for teacher certification from the Texas Education Agency. Additionally, the school district hiring policies may prohibit employment if any applicant has a criminal conviction. We recommend candidates carefully review TEA's requirements and connect with any district of interest to understand their specific hiring guidelines regarding criminal histories. This will allow you to make an informed decision about pursuing certification and employment in the education field in Texas.

Revised Texas Education Code §22.083 authorized the Region 7 Education Service Center to obtain terminal history information on every applicant.

I am an applicant for participation in the Region 7 ESC education preparation program and have been advised that as part of the application process, Region 7 ESC conducts a criminal history background check. I do hereby authorize REiong 7 ESC to obtain, use, and evaluate my criminal history record for consideration of admissions as outlined in Texas Education Code §22.083. I understand that REgion 7 ESC has the right to refuse admittance to the program based on information provided by the Texas Department of Public Safety on the criminal history check. In addition, I have been informed that I will have a reasonable opportunity to clear up any mistaken information reported within a reasonable time frame established within the sole discretion of Region 7 ESC.

By typing your full name here, you consent to a background check.

Today's Date*

Answer Required

Full Name (first, middle, and last) *

Answer Required

Maiden or other name(s) used in any and all other records of birth or records of residence.

Answer Required

Date of Birth (to be used for criminal checks and demographic reporting only and not part of the application approval process).*

Answer Required

Have you ever been convicted or pled guilty before a court for any federal, state, or municipal criminal offense? (Include all felony or misdemeanor offenses. Exclude any minor traffic misdemeanors.)*

Answer Required

Yes

If yes, provide written details of the occurrence(s). Include the date of offense, county, state of offense, and details of conviction.

Answer Required

Have you ever received deferred adjudication or similar disposition for any federal, state, or municipal offense?*

Answer Required

Yes

If yes, provide written details of the occurrence(s). Include the date of offense, county, state of offense, and details of conviction.

Answer Required

Have you ever received probation or community supervision for federal, state, or municipal offenses?*

Answer Required

Yes

If yes, provide written details of the occurrence(s). Include the date of offense, county, state of offense, and details of conviction.

Answer Required

Have you ever been convicted of any criminal offense outside of the jurisdiction of the United States?*

Answer Required

Yes

If yes, provide written details of the occurrence(s). Include the date of the offense and details of the conviction.

Answer Required

As of the date of this consent form, do you have any pending charges against you?*

Answer Required

Yes

If yes, provide written details of the occurrence(s). Include the date of the offense and details of the conviction.

Answer Required

CCH Verification

I have been notified that a computerized criminal history (CCH) verification check will be performed by the agency below accessing the Texas Department of Public Safety Secure Website and will be based on the name and DOB information I supply.

Because the name-based information is not an exact search and only fingerprint record searches represent true identification to criminal history, the organization (as listed below) conducting the criminal history check is not allowed to discuss any information obtained using this method, therefore the agency may offer the opportunity to have a fingerprint search performed to clear any misidentification based on the name search if the search provides a criminal report I know could not be mine.

For the fingerprint process, I will be required to submit a full and complete set of my fingerprints for analysis through the Texas Department of Public Safety AFIS (automated fingerprint identification system). I have been made aware that in order to complete this process, I must have the correct fingerprint (FAST) form from this agency, make an online appointment, submit a full and complete set of my fingerprints, and pay a fee of $49.00 to the fingerprinting services company. All this will be completed through my Texas Education Agency account. Once this process is completed and the agency receives the data from DPS, the information on my fingerprint criminal history record may be discussed with me.

I agree with this statement. By typing your full name, you consent to a criminal history verification check.

Full Name (first, middle, and last) and Today's Date*

Answer Required

TEA Information

The United States Department of Education (USDE) requires all state and local education institutions to collect data on ethnicity and race for students and staff. This information is used for state and federal accountability reporting as well as for reporting to the Office of Civil Rights (OCR) and the Equal Employment Opportunity Commission (EEOC).

School District staff and parents or guardians of students enrolling in school are requested to provide this information. If you decline to provide this information, please be aware that the USDE requires school districts to use observer identification as a last resort for collecting the data for federal reporting.

Please answer both parts of the following questions on ethnicity and race. United States Federal Register (71 FR 44866).

Ethnicity*

Answer Required

Gender*

Answer Required

First Name*

Answer Required

Last Name*

Answer Required

TEA Testing ID#

Answer Required

By typing your FULL NAME and TODAY'S DATE here, you consent to sharing your ethnicity/race information.*

Answer Required

Professional Recommendation

First & Last Name*

Answer Required

Title*

Answer Required

Relationship*

Answer Required

Address*

Answer Required

City*

Answer Required

State*

Answer Required

Zip/Postal*

Answer Required

Email*

Answer Required

Phone*

Number Required

Public Information Act - Personal Information Disclosure

First Name*

Answer Required

Last Name*

Answer Required

Street Address*

Answer Required

City*

Answer Required

State*

Answer Required

Zip/Postal*

Answer Required

Phone*

Number Required

Date of Birth*

Answer Required

Typing your FULL NAME and TODAY's DATE here represents your digital signature for this section of the application.*

Answer Required

Confirmation Email

Email Required

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