First Name *       Last Name *
Best Phone *( ) -       Phone Type
Other Phone( ) -       Phone Type
Email *
Street Address *
City *    State *    Zip *
How did you hear about the Reading Endorsement/Certificate
What is your highest level of education?
Do you currently hold a valid teaching license? Yes  No
If yes, how long have you been teaching?
If yes, which students do you teach (check all that apply)? Elementary
Middle
High
Do you hold any of the following endorsements on your license?

Are there any questions you may have?

Type the characters that you see in the picture above:
If you are unable to see the picture, please contact Amber Deets at deetsa@wou.edu, or 503-838-8492.