CATHERINE LEAHY BRINE EDUCATIONAL CONSULTANTS, INC.
98 RANDOLPH STREET
S. WEYMOUTH, MA 02190
APPLICATIOPN COVER SHEET FOR ALL PROGRAMS
*** A $150.00 NON-REFUNDABLE APPLICATION FEE MUST ACCOMPANY THIS COVER SHEET.
SEMESTER FOR WHICH I AM APPLYING (Circle One and Add the Year) September __________ January__________ April__________
PROGRAM FOR WHICH I AM APPLYING (Circle One)
M. Ed with Professional License M. Ed with Initial License M.Ed with no license 12 Credit Professional License Only 21 or 24 Initial License Only Ed. Leadership M. Ed Ed Leadership CAGS Reading Specialist M.Ed Reading Specialist CAGS
FIRST MI   MAIDEN/OTHER ADDRESS:____________________________________________________________________________________
STATE ZIP CODE HOME TELEPHONE: ______________________ CELL PHONE________________________ SOCIAL SECURITY NUMBER: ___________________ MEPID_________________ Date of Birth ____________________ E-MAIL ADDRESS ___________________________________________________________ Ethnicity/Race (for reporting purposes, optional) Do you consider yourself Hispanic/Latino? ___ Yes ___ No
Select one or more of the following racial categories to describe yourself:
___ American Indian/Alaskan Native ___ Asian ___ Black or African American ___ Cape Verdean
___ Native Hawaiian or Pacific Islander ___ White
LICENSE CURRENTLY HELD FROM MA. DESE: (Circle One)
FIELD: ______________________________________(example: History, 5-8)
COHORT SITE PREFERENCE
****We will run a cohort anywhere as long as there are FIFTEEN applicants.****
PLEASE READ THIS SECTION CAREFULLY BEFORE SIGNING:
I understand that Catherine Leahy Brine, Inc. is not responsible for any misinformation given to the agency, office staff or instructors by me regarding my license from the Massachusetts Department of Elementary and Secondary Education. I understand that I must hold a Preliminary license to be enrolled in the Initial License Programs and the Initial License to be enrolled in the Professional. I understand that if programs or regulations change the program and its requirements may change as well with or without notice.
APPLICANT'S SIGNATURE ______________________________________________________ DATE ____________________
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