4/2017
HTSB Form HP 1008
www.htsb.org
[email protected]
Phone: 808-586-2600
Hawai`i Teacher Standards Board
650 Iwilei Road, Suite 201
Honolulu, HI 96817
Attention: Licensing Section
Application for a five-year, single-renewal Special Permit in Kaia ̒ōlelo‐Kaiapuni Hawai ̒i, Hawaiian Language
Immersion and Hawaiian Knowledge
Submit this application and supporting verification form, HP 3009 Office of Hawaiian (OHE) Recommendation, to the
Hawaii Teacher Standards Board. HTSB cannot complete the processing of your application until both documents are
received.
Have you remembered to:
Complete all information on this application and supporting documents.
Sign and date this application.
Make a copy of this application and supporting documents for your records.
Create an HTSB online account so you will be notified by email to go to www.htsb.org to make payment by eCheck or
credit card when your application is complete.
SECTION 1. PERSONAL INFORMATION All fields must be answered.
Social Security Number _______________________________
Date of Birth
_______ /________/__________
MM
DD
YYYY
Print name in CAPITAL LETTERS.
_____________________________
(LAST NAME)
_____________________________________
(FIRST NAME)
___________
(MI)
Former/Maiden Name(s), if applicable:
____________________________
(LAST NAME)
______________________________________
(FIRST NAME)
Mailing Address ________________________ City _____________
State _____
___________
(MI)
Zip Code ________
Home Phone _________________________________ AND/OR Cell Phone _____________________________
Non-Lotus Notes E-mail Address ____________________________________________________________
Are you employed by the Hawai`i Department of Education?
YES
NO
If employed provide the name of the school or education office: __________________________________
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HTSB Form HP 1008
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SECTION 2. PROFESSIONAL FITNESS
YES
NO
Have you ever had a professional license or professional certificate sanctioned or disciplined by receiving
a letter of censure, warning, reprimand, fine, probation or any other restriction or special condition?
YES
NO
Have you ever been denied a professional license or certificate even if the certificate or license was later
issued with conditions or limitations?
YES
NO
Have you ever had a professional license or certificate suspended or revoked?
YES
NO
Have you ever surrendered or relinquished a professional license or certificate during or following an
investigation into allegations of misconduct?
YES
NO
Do you have any current investigative or disciplinary action pending against a professional license or
certificate or against an application for a professional license or certificate?
YES
NO
Have you ever been dismissed or resigned employment during or following an investigation into
allegations of misconduct?
YES
NO
Have you been convicted or pled “nolo contendere” (no contest) to a felony or misdemeanor?
If you answered “yes” to any of the above questions, additional documentation will be requested by letter after review of
your application.
SECTION 3. PERMIT FIELDS REQUESTED Check the field(s) you are requesting. Check all that apply.
Kaia ̒ōlelo‐Kaiapuni Hawai ̒i
Hawaiian Language Immersion
Hawaiian Knowledge
SECTION 4. PERMIT REQUIREMENTS.
All of the following requirements and the Field(s) requested above must be verified by the Office of Hawaiian
Education (OHE) using HTSB Hawaiian Language and Knowledge Recommendation Form HP 3009.
1. Official academic transcripts from high school and/or post-secondary course work;
2. Assessment for Hawaiian language conducted by an Hawaiian Language Immersion Educator Preparation Program
(HLI EPP) or by the Office of Hawaiian Education (OHE);
3. Completion of thirty hours of induction conducted by an HLI EPP or the OHE;
4. Completion of a professional development plan on how a license will be obtained, monitored by an HLI EPP or the
OHE
HOW TO VERIFY REQUIREMENTS HAVE BEEN MET AND TEACHING FIELD ELIIGIBILTY:
Submit HTSB Form HP 3009 Hawaiian Language and Knowledge Recommendation to the OHE.
Contact phone number: 808-305-9723
SECTION 5. FEE
You must create an account with the Hawaii Teacher Standards Board at www.htsb.og. You will be notified by email to
pay your permit fee when all requirements are met. You may pay online using a credit or debit card or checking account
number (eCheck).
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HTSB Form HP 1008
3/2017
Payment using the MyHTSB online account will automatically issue your special permit, allow you to print a copy of your
special permit, and display your new permit information in the HTSB License Search for the public. The online system
vendor, eHawaii.gov, charges an administrative fee to support the online system but HTSB will pay this fee for you when
you pay online.
Payment Using the MyHTSB Online
Account
Permit Fees
Annual Payment
$48.00
Administrative
Fee charged by
eHawaii.gov is
paid by HTSB
$5.80
Your Total
$48.00
Late payments may incur a $25 charge. All payments are non-refundable.
SECTION 6. STATEMENT OF AFFIRMATION Print this form, sign your name in blue ink, and mail to HTSB or attach it to
your MyHTSB account.
I certify that the statements contained in this application are true and correct. I understand that misrepresentation or
falsification is grounds for Board refusal to deny my Permit or impose other disciplinary sanctions.
SIGNATURE OF APPLICANT________________________________________DATE______________________
Information on application is subject to release pursuant to the Freedom of Information Act. Once submitted,
applications and supporting documentation become the property of the Hawai`i Teacher Standards Board
and cannot be returned.
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