LICENSURE ONLY -- SCHOOL LIBRARY MEDIA COORDINATOR

APPLICATION FORM

If you wish to apply for the certification program for school library media coordinators provided by the School of Information and Library Science, please complete the form below and submit it.
If you have any questions, contact Program Director Evelyn Daniel directly at email: daniel@ils.unc.edu or by telephone: 919-962-8062.

Hit the Send key at the bottom of the page when you have finished entering. If you wish to start over, hit Restart.

Name:

First Name:
Last Name:

Contact Information:

Email:
Telephone: (Day): (Night):
Street Address:
City/Town:	State:	Zip code:

Social Security Number: Note: This will be your future license number.

Date of Birth:

Prior Education:

Please list degrees with major subject and school from which you received the degree:

Education Courses:

Please list below the education courses you have taken: course number, title, date completed.

Library Science courses:

Please list below the library science courses you have taken: LIS school, course number, title, date completed.

Licensure: if you have, or have had, a license in another teaching area and/or in another state, please list it here. Include state, license number, title, date received.

Relevant Experience:

If you have taught, worked as a librarian, or as a teacher or library aide, please list your experience here. Include places and dates.

Additional Comments:

If you wish to provide additional information or have a question to ask, use the space below.

Thank you for submitting your application. This form will be sent to Program Director Dr. Evelyn Daniel (daniel@ils.unc.edu). If you do not hear from her within two weeks, please contact her by email or telephone (919-962-8062).

Revised 7/12/2002.