Catherine Leahy-Brine, Inc. MA Professional Development Provider

Massachusetts
Professional Development Provider
Certification
7-0089-999

Catherine Leahy-Brine
Educational Consultants, Inc.
P.O. Box 1060
Brockton, Ma 02303
Phone 781-331-8826
Fax 781-337-6152
Email: Catherine Leahy Brine

COVER SHEET FOR
FITCHBURG STATE COLLEGE SITE-BASED MASTER OF EDUCATION AND
CATHERINE LEAHY BRINE, INC. LICENSURE PROGRAMS

SEMESTER FOR WHICH I AM APPLYING FOR (CIRCLE ONE)
APRIL 2007                   SUMMER 2007                   FALL 2007

PROGRAM THAT YOU ARE APPLYING FOR (Circle One)

*Professional License Program Only      **M.Ed. Only     *Combo: M.Ed. with Professional License
*Initial License Program Only     *Combo: M. Ed. with Initial License
*M. Ed. SPED with Initial in Reading     *CAGS/M. Ed. Educational Leadership/Management
*M. Ed. Early Childhood & Elementary Ed. Initial Licensure

LICENSE AND FIELD HELD FROM THE DOE: _______________________________________________________

NAME: _______________________________________________________________________________________

                LAST
FIRST MI         MAIDEN/OTHER

ADDRESS:____________________________________________________________________________________

                   NUMBER/STREET

                 ____________________________________________________________________________________

                   CITY/TOWN
STATE ZIP CODE

HOME TELEPHONE: ______________________                  CELL PHONE________________________

SOCIAL SECURITY NUMBER: ___________________             BIRTHDAY ____________________

E-MAIL ADDRESS___________________________________________________________

COHORT SITE PREFERENCE
(Circle One)
Minimum of 15 required for a site to run.
BROCKTON
MARSHFIELD
ROCKLAND
CAPE COD
WEYMOUTH

DEDHAM
GLOUCESTER
METHUEN
OTHER__________________

****We will run a cohort anywhere requested as long as there are FIFTEEN applicants.****
PLEASE READ THIS SECTION CAREFULLY BEFORE SIGNING:

I grant Catherine Leahy Brine Educational Consultants permission to open all official transcripts sent to the agency in order to build my application file. I understand that the only item that is sent to Fitchburg State College directly is my official GRE/MAT score from the test agency. I understand that my application must be complete before classes begin.
I understand that Catherine Leahy Brine Inc. is not responsible for any misinformation given to the agency, the office staff, or instructors by me regarding my license from the Massachusetts Department of Education. I understand that I must hold an Initial License from the Massachusetts Department of Education in order to be enrolled in the Professional Licensure Program.

APPLICANT'S SIGNATURE _______________________________ DATE ____________________
Please mail in this coversheet ASAP if you intend on applying to the program. Having this information allows us to begin to set up cohort sites dependent on applicant numbers.

Back to Application.

COVER SHEET FOR FITCHBURG STATE COLLEGE SITE-BASED MASTER OF EDUCATION AND CATHERINE LEAHY BRINE, INC. LICENSURE PROGRAMS SEMESTER FOR WHICH I AM APPLYING FOR (CIRCLE ONE) APRIL 2007 SUMMER 2007 FALL 2007
PROGRAM THAT YOU ARE APPLYING FOR (Circle One)
Professional License Program Only M.Ed. Only Combo: M.Ed. with Professional License Initial License Program Only Combo: M. Ed. with Initial License M. Ed. SPED with Initial in Reading CAGS/M. Ed. Educational Leadership/Management *M. Ed. Early Childhood & Elementary Ed. Initial Licensure
LICENSE AND FIELD HELD FROM THE DOE: _______________________________________________________
NAME: _______________________________________________________________________________________
LAST	FIRST	MI MAIDEN/OTHER
ADDRESS:____________________________________________________________________________________
NUMBER/STREET
____________________________________________________________________________________
CITY/TOWN	STATE	ZIP CODE
HOME TELEPHONE: ______________________ CELL PHONE________________________
SOCIAL SECURITY NUMBER: ___________________ BIRTHDAY ____________________
E-MAIL ADDRESS___________________________________________________________
COHORT SITE PREFERENCE (Circle One) Minimum of 15 required for a site to run.	BROCKTON MARSHFIELD ROCKLAND CAPE COD WEYMOUTH	DEDHAM GLOUCESTER METHUEN OTHER__________________
**We will run a cohort anywhere requested as long as there are FIFTEEN applicants. PLEASE READ THIS SECTION CAREFULLY BEFORE SIGNING:**
I grant Catherine Leahy Brine Educational Consultants permission to open all official transcripts sent to the agency in order to build my application file. I understand that the only item that is sent to Fitchburg State College directly is my official GRE/MAT score from the test agency. I understand that my application must be complete before classes begin. I understand that Catherine Leahy Brine Inc. is not responsible for any misinformation given to the agency, the office staff, or instructors by me regarding my license from the Massachusetts Department of Education. I understand that I must hold an Initial License from the Massachusetts Department of Education in order to be enrolled in the Professional Licensure Program.
APPLICANT'S SIGNATURE _______________________________ DATE ____________________ Please mail in this coversheet ASAP if you intend on applying to the program. Having this information allows us to begin to set up cohort sites dependent on applicant numbers.