Free 26859.xls - Indiana

APPLICATION FOR PUBLIC LIBRARY CERTIFICATE
State Form 26859 (R4 / 5-08) Approved by State Board of Accounts, 2008

CERTIFICATION PROGRAM COORDINATOR Professional Development Office, Indiana State Library 140 North Senate Avenue, Indianapolis, IN 46204-2296 317-234-5650 or 1-800-451-6028 (Indiana only) Fax: 317-232-3713 WWW: http://www.IN.gov/library E-mail: [email protected]

INSTRUCTIONS: 2. Send a certified copy of your transcript along with the application. 3. Send a check or money order for $50 payable to the Indiana State Library.

1. Fill out the application form completely. Only supply one address (work or home).

4. Mail the application to the Professional Development Office, address is listed at the above right. NOTE: Information provided is a public record Date (month, day, year ) Personal/Work E-mail: Last Name First Name Middle Name Maiden Name (if applicable ) Telephone (include area code )

Home Address (number and street, city, state and ZIP code ) Library Name Work Address (number and street, city, state and ZIP code )

Please check the type and level of certification in which you are applying in the space below .

Type Librarian Specialist Temporary
Please list the highest degree obtained

Level 1 2 3 4 5 6

GENERAL EDUCATION (NOT Library Training. This goes under NEXT heading.)
School Attended Dates of Attendance Dates of Graduation Degree

LIBRARY EDUCATION
NAME OF INSTITUTION AND STATE 1. ALA-Accredited Library School Dates of Attendance College Credits Received Degree/Diploma and Date

(i.e.,degree obtained )
2. Approved Library Science Education

(590 IAC 5-1-6)
(If more space is needed, use an additional sheet repeating headings.Dates should include beginning and ending day, month, and year.)

PROFESSIONAL LIBRARY EMPLOYMENT
NAME OF LIBRARY AND STATE Present Position Previous Position Previous Position INSTRUCTIONS: Applicant must be sure to supply all signatures called for below. The information given in the application is correct, and on the basis of it, I, the applicant, apply for, Certificate as (Class or Grade ) I enclose $50.00 Temporary Permit as (Class or Grade ) Position Held Dates Principal Duty

in

Personal check

Money Order

Applicant's Signature