Diocese of Columbus Office of Catholic Schools REQUEST FOR PERMANENT NON-TAX CERTIFICATE Teacher Name: State ID (if known): DOB: School: City: Reason: (check one or more) Teacher will be teaching religion at the Secondary Level (grades 7-12) Teacher will be teaching religion at the Middle Childhood Level (grades 4-9) and holds a subject-specific license A qualified licensed candidate could not be located or hired Add grade level(s) or subject(s) not listed on teacher’s license If teacher does not have experience teaching in a school setting, we understand that a mentor will be provided and the teacher and mentor will participate in the Diocesan Resident Educator program. Mentor Name (if known): Subject Area/Grade Level: Academic and/or Employment Background that qualifies this teacher to teach this subject area and/or grade level: (include degree(s), relevant coursework, relevant work experience, teaching experience, etc.)

Please attach a plan with timeline to complete professionalization of license, if applicable (if license is not for teaching Religion) Teacher, please complete the following section by initialing each requirement as applicable. I understand that I will be required to complete the following requirements: Apply for a “Permanent Non-Tax Certificate – N/A” through the Ohio Department of Education(ODE) Website using my SAFE account and the IRN 052530 Complete and submit an Individual Professional Development Plan (IPDP) to the Local Professional Development Committee (LPDC) Complete and submit transcripts and/or CEUs for 6 semester hours, 9 quarter hours, 18 CEUs or an equivalent combination in order to renew my certificate through the LPDC every 5 years Keep my FBI Background checks up-to-date (every 5 years) Work with a mentor through the Diocesan Resident Educator Program for the first two years of my employment if I do not have prior K-12 teaching experience Complete the requirements for the first 2 years of the Diocesan Resident Educator Program in the first two years of my employment Complete ODE requirements to gain regular licensure in my subject area and/or grade level within the first 3 years of my employment (if applicable) In order to gain Professional licensure I must complete ODE requirements which may include approval of 4 Year Resident Educator License or 4 Year Alternative Resident Educator License If I earn a 4 Year Resident Educator License or a 4 Year Alternative Resident Educator license, I will be required to participate in the Resident Educator Program and complete all its requirements during the term of this license If I am a teacher of religion, I must complete the Office of Religious Education and Catechesis requirements for the renewal of my certification Administrator Signature

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Teacher Signature

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I approve this request. Superintendent Signature Comments/Additional Requirements:

Columbus Diocese Non-Tax Approval Form

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Revised 2016