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Minnesota Teacher Candidate Grant Application


Applicant Information

Check the term for which you are applying to receive this grant (you must be completing an eligible student teaching experience in this term to be eligible for this award):

Student Info – All information is required

First Name:


Middle Name:


Last Name:


Date of Birth:

Social Security Number
(format: 999999999)


Phone:


Mailing Address


City,                                 State      Zip Code
(format: 55406 or 554061234)


Permanent Mailing Address


City,                                 State      Zip Code
(format: 55406 or 554061234)


Email Address

Re-type Email Address

College or University:

Race and Ethnicity – Optional

Questions in this section are optional however teacher candidates who belong to a racial or ethnic group underrepresented in the Minnesota teacher workforce are given priority in the awarding process.   
Are you Hispanic or Latino? (i.e., a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture, regardless of race)                    


Teacher Licensure Field and Student Teaching Experience Placement Info – Optional

Questions in this section are optional.  If you are selected for an award, your college or university will be required to provide the information before any payment.

Teacher licensure field

School/location

Applicant Certification and Permission for Release of Information

Please check the box next to each statement indicating that you have read and agree to the statement:

Applicant's Signature (type name):    Date: 09/29/2020


Notice to Applicants

Section 7(b) of the Federal Privacy Act of 1974 (5 U.S.C. 552a) requires that when any federal, state, or local government agency asks you to disclose your Social Security Account number, you must be advised whether that disclosure is mandatory or voluntary, by what statutory or other authority the number is solicited, and what uses will be made of it. The Social Security number will be used by the Minnesota Office of Higher Education (MOHE) to verify your identity, and as an identifier of your file in order to record necessary data accurately. As an identifier, the Social Security number is used in the Teacher Candidate Grant program for such purposes as processing the application form, program evaluation, and reporting. You are being advised that disclosure of your Social Security number is voluntary. However, failure to submit your Social Security number may prevent further processing of this form.

Pursuant to Minnesota Statutes, Sec. 13.04, subd. 2, you are hereby informed that the information supplied in this form may be used as follows: (1) in the processing and verification of the data supplied to determine your eligibility for this program; and (2) for compilation and analysis of summary data relative to this program. Private data, including identifying information, will not be disclosed under Minnesota Statutes, Sec. 13.32, unless otherwise stated by statute or at the request of the Legislative Auditor. You are not required to provide the information supplied in this form. However, failure to submit requested data may prevent further processing of this form. The information supplied in this form may be shared with other public and private individuals and entities in order to use the information for the purposes specified above.

The Office of Higher Education does not discriminate on the basis of disability in the admission or access to, or treatment or employment, in its programs or activities. This document can be made available in an alternative format to individuals by calling (800) 657-3866 or (651) 642-0567.