First Name

Middle Name or Initial (If you do not have a middle name, please put N/A)

Last Name

Suffix

Prior name if applicable:

SSN:

Email Address (Please use your school email address and use this email with future communications with us)

Are you of Hispanic/Latino Ethnicity or Descent?

YesNo

Please one or more races with which you identify yourself:

Cell Phone Number

Phone Number

Date of birth:

Please indicate your marital status:

Employer/Organizational Name:

What grade do you teach?

Do you have a valid Virginia Educator's license?

YesNo

What is your area of focus?

Have you ever applied to or attended Averett University in the past?

YesNo

If yes, please indicate when:

By checking this box, I understand the purpose of taking this course is to increase the number of teachers qualified to work with English Learners in the commonwealth of Virginia, and I intend to register for and take Praxis test #5362 - ESOL to become endorsed as an ESL teacher in Virginia.

YesNo