Application and Information

NOTICE: The applicant will be required to upload a single PDF that a receipt of payment indicating the payee and a Request for Taxpayer Identification Number and Certification W-9 (https://www.irs.gov/pub/irs-pdf/fw9.pdf)

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* 1. What is your first name?

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* 2. What is your middle name?

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* 3. What is your last name?

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* 4. What is your mailing address? (Line 1)

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* 5. What is your mailing address? (Line 2 if needed)

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* 6. What is your mailing address city?

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* 7. What is your mailing address zip code?

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* 8. What is your daytime contact phone number (XXX-XXX-XXXX)?

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* 9. What is your workplace phone number (XXX-XXX-XXXX)?

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* 10. What is your work email address?

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* 11. What is your Arkansas Educator Licensure System Case ID number. (This can be located by going to https://adeaels.arkansas.gov/AelsWeb/Search.aspx, searching your name, locating your record, and then looking in the upper left hand corner of the web page in the box labeled "Case ID.")

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* 12. I hold a 528 Computer Science endorsement and am seeking reimbursement for:

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* 13. The entity that paid the licensure application/renewal fee and will receive the reimbursement is:

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* 14. I am aware that if I hold the 528 Endorsement on my Arkansas Educator's License I may be eligible for up to $2000.00 in stipends

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* 15. Upload a completed Request for Taxpayer Identification Number and Certification W-9 (https://www.irs.gov/pub/irs-pdf/fw9.pdf), or if your district paid for your licensure renewal, please upload an invoice from your district for the license renewal fee.

PDF file types only.
Choose File

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* 16. Upload a receipt for payment if the applicant paid the renewal and is seeking personal reimbursement, or if your district paid for your licensure renewal, please upload an invoice from your district for the license renewal fee (we realize this might be a duplicate submission).

PDF file types only.
Choose File

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* 17. I understand that I, as an individual holding an Arkansas Educator's License, am bound by The Code of Ethics for Arkansas Educators. Standard 3 states, "[a]n educator honestly fulfills reporting obligations associated with professional practices." Any submissions of this form that the ADE Office of Computer Science believes may be in violation of this standard will be reported to the ADE Professional Licensure Standards Board.

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* 18. I understand that I am responsible for proper reporting of any received income and any subsequent federal and/or state taxes. If I receive more than $600.00 in a calendar year, I will receive a 1099 from ADE.

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