Catherine Leahy-Brine, Inc. MA Professional Development Provider

CATHERINE LEAHY BRINE EDUCATIONAL CONSULTANTS, INC.
98 RANDOLPH STREET
S. WEYMOUTH, MA 02190
781-331-8826

COVER SHEET FOR PROGRAMS OFFERED THROUGH CATHERINE LEAHY BRINE

*** A $125.00 NON-REFUNDABLE APPLICATION FEE MUST BE ATTACHED TO THIS COVER SHEET.

SEMESTER FOR WHICH I AM APPLYING (Circle One)
September 2009                                 January 2010                                 April 2010

PROGRAM FOR WHICH I AM APPLYING (Circle One)

PROFESSIONAL LICENSE PROGRAM ONLY    INITIAL LICENSE PROGRAM ONLY    M ED PROGRAM ONLY    COMBO OF BOTH
EDLM M.ED      EDLM CAGS      INTERDISCIPLINARY CAGS      M.ED IN SPECIAL EDUCATION: READING SPECIALIST

LICENSE HELD FROM THE DOE:    Circle One:        PRELIMINARY     INITIAL
                                                                                              FIELD: __________________
                                                                                                               (e.g. History 5-8)

NAME: _______________________________________________________________________________________

                LAST
FIRST MI         MAIDEN/OTHER

ADDRESS:____________________________________________________________________________________

                   NUMBER/STREET

                 ____________________________________________________________________________________

                   CITY/TOWN
STATE ZIP CODE

HOME TELEPHONE: ______________________                  CELL PHONE________________________

SOCIAL SECURITY NUMBER: ___________________             Date of Birth ____________________

PRIVATE E-MAIL ADDRESS (not school)___________________________________________________________

COHORT SITE PREFERENCE
(Circle One)

BROCKTON
MARSHFIELD
WEYMOUTH

DEDHAM
CAPE COD
OTHER__________________

****We will run a cohort anywhere 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 for acceptance by the college into the M.Ed. program, my application must be complete before classes begin and/or the "drop dead" date given by the college.
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 or the Preliminary License to be enrolled in the Initial License Program.

APPLICANT'S SIGNATURE _______________________________ DATE ____________________
Please mail in this coversheet ASAP if you intend on applying to the program. We use this data to decide upon/plan sites.

Back to Application.

COVER SHEET FOR PROGRAMS OFFERED THROUGH CATHERINE LEAHY BRINE * A $125.00 NON-REFUNDABLE APPLICATION FEE MUST BE ATTACHED TO THIS COVER SHEET. SEMESTER FOR WHICH I AM APPLYING (Circle One)** September 2009 January 2010 April 2010
PROGRAM FOR WHICH I AM APPLYING (Circle One)
PROFESSIONAL LICENSE PROGRAM ONLY INITIAL LICENSE PROGRAM ONLY M ED PROGRAM ONLY COMBO OF BOTH EDLM M.ED EDLM CAGS INTERDISCIPLINARY CAGS M.ED IN SPECIAL EDUCATION: READING SPECIALIST
LICENSE HELD FROM THE DOE: Circle One: PRELIMINARY INITIAL FIELD: __________________ (e.g. History 5-8)
NAME: _______________________________________________________________________________________
LAST	FIRST	MI MAIDEN/OTHER
ADDRESS:____________________________________________________________________________________
NUMBER/STREET
____________________________________________________________________________________
CITY/TOWN	STATE	ZIP CODE
HOME TELEPHONE: ______________________ CELL PHONE________________________
SOCIAL SECURITY NUMBER: ___________________ Date of Birth ____________________
PRIVATE E-MAIL ADDRESS (not school)___________________________________________________________
COHORT SITE PREFERENCE (Circle One)	BROCKTON MARSHFIELD WEYMOUTH	DEDHAM CAPE COD OTHER__________________
**We will run a cohort anywhere 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 for acceptance by the college into the M.Ed. program, my application must be complete before classes begin and/or the "drop dead" date given by the college. 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 or the Preliminary License to be enrolled in the Initial License Program.
APPLICANT'S SIGNATURE _______________________________ DATE ____________________ Please mail in this coversheet ASAP if you intend on applying to the program. We use this data to decide upon/plan sites.