INITIAL LICENSE APPLICATION for 2017-2019 Forms/PTVT_Initial_17-19.pdfCert if icat es Diplomas Degrees A ward Dat e (mm/yy) C. TEACHING EXPERIENCE (if none l eave bl ank) Name and

DAVID Y. IGE GOVERNOR

STATE OF HAWAI`I

DEPARTMENT OF EDUCATION Office of Curriculum, Instruction and Student Support

475 22nd Avenue, Room 209 Honolulu, Hawaii 96816

Phone: (808) 305-9755 Fax: (808) 733-9154 E-mail: [email protected]

KATHRYN S. MATAYOSHI SUPERINTENDENT

INITIAL LICENSE APPLICATION for 2017-2019 FOR PRIVATE TRADE, VOCATIONAL OR TECHNICAL SCHOOLS

Private Trade, Vocational or Technical (PTVT) School License renewal applications are processed every two years during odd-numbered years (i.e., 2017, 2019, etc.) and are due by July 1st of the expiring year. Licenses are granted from September 1 to August 31 for two years. The initial licensing fee is $100.00 and must be submitted with the initial application. Until licensed by the Hawaii State Department of Education, no school shall advertise, accept tuition from prospective students, or schedule classes. Instructions and Checklist: ◻ Review Hawaii Administrative Rules, Title 8, Chapter 101, Licensing of Private,

Trade, Vocational or Technical Schools. All schools and staff must comply with the Hawaii Administrative Rules, Title 8, Chapter 101. A licensed school shall make available a copy of this chapter to members of the staff and students upon request.

◻ REQUIRED DOCUMENTS □ School Information (PTVT Form 1i) □ Request for Initial License (PTVT Form 2i) □ Personnel (PTVT Forms 3, 5, 6) Note: Form 4 is not required for the Initial License □ Curriculum (PTVT Forms 7-9) Note: Forms 10 and 11 are not required for the Initial License □ Projected Summary of Fiscal Operations (PTVT Form 12) □ Articles of Incorporation and By Laws □ State General Excise Tax License □ Brochure/Catalog and Sample of School Certificate □ Surety Bond (Affidavit) □ License Fee □ Facilities

□ Hawaii State Department of Health □ City and County of Honolulu-Building Division □ City and County of Honolulu-Fire Department □ Floor Plan

□ Certification of Applicant

AN AFFIRMATIVE ACTION AND EQUAL OPPORTUNITY EMPLOYER

http://www.hawaiiboe.net/AdminRules/Pages/AdminRule101.aspx

INITIAL LICENSE APPLICATION For Private Trade, Vocational, or Technical Schools

License Application for 2017-2019

Instructions and Checklist (continued): SCHOOL INFORMATION □ Complete School Information (PTVT Form 1i) REQUEST FOR INITIAL LICENSE □ Complete Request for Initial License (PTVT Form 2i) PERSONNEL ◻ Instructors

▪ Application for Professional Staff Certificate (PTVT Form 3) ▪ Evidence that a standard learning period has been completed and passed for

the trade or vocation noted (i.e., resume, transcripts, diploma/certificate) ▪ Employment verification of a minimum of 5,400 hours (approximately three (3)

years) of work experience for the trade or vocation noted ▪ Current Hawaii licenses for the trade or vocation noted (i.e., massage,

acupuncture, crane operations, etc.) ▪ Current and valid tuberculosis clearance certificate ▪ Summary of Instructors Form (PTVT Form 5)

● List all instructors in alphabetical order ● Submit a revised list if there are changes during the school year

▪ Non-Instructional staff members must submit a current and valid tuberculosis (TB) clearance certificate

◻ Principal ▪ Principal Certification Form (PTVT Form 6) ▪ Documentation of Training and Experience ▪ Three (3) Letters of Verification

Note: After a school has been licensed, any changes shall be reported to the Hawaii State Department of Education within five (5) business days from the date of change. Changes can be sent via e-mail to [email protected].

2 Hawaii State Department of Education Office of Curriculum, Instruction and Student Support



Instructions and Checklist (continued): CURRICULUM ◻ Complete Course Log and Information Form (PTVT Form 7) ◻ Complete Course Description Form (PTVT Form 8) ◻ Complete Course of Study (PTVT Form 9) FISCAL OPERATIONS ◻ Complete Projected Summary of Fiscal Operations (PTVT Form 12) BROCHURE/CATALOG ◻ Current curriculum (i.e., course of study, course descriptions, etc.) ◻ Course Fees (i.e., tuition, books, supplies, and other fees) ◻ Student Rights ◻ Refund Policy ◻ Grading Policy ◻ Sample Certificate SURETY BOND (AFFIDAVIT) ◻ Submit a current affidavit demonstrating Surety Bond is and will be current for the

program years of licensure. INITIAL LICENSE FEE ◻ Submit Initial License Fee of $100.00 payable to the Hawaii Department of

Education. Hawaii Revised Statutes, Section 40-35.5, Assessment and collection of service charges for dishonored payments , requires all DOE schools and offices receiving revenues or other monies on behalf of the State to assess and collect a service charge in the amount of $25.00 for any remittance for payment that is dishonored for any reason.




Instructions and Checklist (continued): FACILITIES/CERTIFICATES OF INSPECTION If a school relocates to a new address, it must submit updated health, building, fire, and floor plans. Evidence provided must indicate all requirements have been met. ◻ Hawaii State Department of Health ◻ County Building Department (which includes the maximum occupant load) ◻ Fire Inspection ◻ Floor Plan Contact Information Sanitation Compliance Hawaii State Department of Health - Sanitation Branch 99-945 Halawa Valley Street Aiea, Hawaii 96701 Phone: 586-8000 Fire Safety Requirements City and County of Honolulu - Fire Department Fire Prevention Bureau 636 South Street Honolulu, Hawaii 96813-5007 Phone: 723-7161 Safety and Building Code Compliance City and County of Honolulu - Department of Planning and Permitting Building Division 650 South King Street Honolulu Hawaii 96813 Phone: 768-8259 (voice) The Hawaii State Department of Education does not require submission of certificates of clearance showing compliance with the Hawaii Occupation and Safety Health (HIOSH) and the Americans with Disabilities Act (ADA). However, all licensed schools are responsible for the compliance with applicable codes and regulations. For more information and assistance, contact the following offices: Hawaii State Department of Labor and Industrial Relations Occupational Safety and Health Division - Consultation and Training Branch 830 Punchbowl Street, Room 423 Honolulu, Hawaii 96813 Phone: 586-9100 or go to read regulations http://labor.hawaii.gov/hiosh/about-us/ Hawaii State Department of Health Disability and Communication Access Board 919 Ala Moana Blvd., Room 101 Honolulu, Hawaii 96814 Phone: 586-8121 or [email protected]


http://labor.hawaii.gov/hiosh/about-us/

mailto:[email protected]



CERTIFICATION OF APPLICANT This affidavit must be signed and notarized. By submitting this licensing application, I hereby attest that I have reviewed the contents for accuracy. All forms submitted are in compliance with Hawaii Administrative Rules, Title 8, Chapter 101. In addition, I certify the adherence to provisions of the Hawaii Revised Statutes Sections 302A-424 to 302A-428.

Signature of Authorized Officer To be signed in the presence of a Notary Public

Date

Print Name Title

This section to be completed by a Notary Public State of Hawaii, City and County of __________________________ The officer whose true signature appears above, being duly sworn and deposed, certifies that the facts set forth in the above statements are true. Subscribed and sworn to before me this _____ day of ________________ 20 _______

Notary Public Judicial Circuit State of Hawaii My commission expires _______________________________


SCHOOL INFORMATION (PTVT Form 1) License Application for 2017-2019

This information will appear on the school license. Name of School

Provider/Owner (Registered Trade Name)

School Address (Classroom Location)

Business/Mailing Address

Business Telephone

Fax Number

E-mail Address

Web Page URL

School Administrator (Principal)

School Administrator’s Residence Address

Phone Number

E-mail Address

Principal is: ☐ Continuing ☐ New (If new, submit Principal Certification Form and accompanying documents) Vocation(s) List

State General Excise Tax Number

Hawaii State Department of Education Page 1 of 1 Office of Curriculum, Instruction and Student Support

SCHOOL INFORMATION (PTVT Form 1i) License Application for 2017-2019

This information will be used by the Hawaii State Department of Education if a license is approved for this school. Name of School

Provider/Owner (Registered Trade Name)

School Address (Classroom Location)

Business/Mailing Address

Business Telephone

Fax Number

E-mail Address

Web Page URL

School Administrator (Principal)

School Administrator’s Residence Address

Phone Number

E-mail Address

Vocation(s) List

State General Excise Tax Number


REQUEST FOR LICENSE RENEWAL (PTVT Form 2) License Application for 2017-2019

The school license is limited to the specific Name, Location, and Vocation as stated on the license. Check one of the following: ❏ Requesting that a license be issued the same as the previous year. There are no changes and the

license information is correct. ❏ Requesting a change in the license due to the following: ❏ Change in School Name

New Name

Previous Name

❏ Change in Location

New Address

Previous Address

Note: Updated health, building, fire, and floor plans stating that all requirements have been met must accompany this form. ❏ Changes/Additions to Vocation Listing

New Vocation(s) List

Previous Vocation(s) List

❏ Change in Mailing Address

New Address

Previous Address

❏ Change in Ownership Note: A change in ownership status voids the current license. The school must submit a new initial application.


REQUEST FOR INITIAL LICENSE (PTVT Form 2i) License Application for 2017-2019

The school license is limited to the specific Name, Location, and Vocation as stated on the license.

School Name

Location

Vocation(s) List

Form of Ownership Corporation Partnership Sole Proprietorship Limited Liability Company (LLC) Limited Liability Partnership (LLP)

List all individuals who own 5 percent or more of the school:

Legal Name Mailing Address E-Mail Address

Have any of the individuals listed above ever: 1. Been connected in any capacity with a private trade, vocational, or technical school of any type? If yes,

explain. 2. Been convicted for violating the penal laws of the United States related to the profession or business for

which this license is being sought? If yes, explain.


APPLICATION FOR PROFESSIONAL STAFF CERTIFICATE (PTVT Form 3) License Application for 2017-2019

Complete this form and attach the following for each instructor: ❏ Evidence that a standard learning period has been completed and passed for the trade or vocation

noted (i.e., resume, transcripts, diploma/certificate) ❏ Employment verification of a minimum of 5,400 hours (approximately three (3) years) of work

experience for the trade or vocation noted ❏ Current Hawaii licenses for the trade or vocation noted if required of instructors by law or ordinance ❏ Current and valid tuberculosis clearance certificate

A. PERSONAL INFORMATION

Legal Name (Last, First, Middle)

Social Security Number xxx-xx-

Mailing Address

Phone Number E-mail Address

Trade/Vocation Certification Areas

B. EDUCATIONAL AND PROFESSIONAL TRAINING

Name and Location of Schools Attended (High, Technical, Vocational Schools and Colleges)

Area of Study or Major

From (mm/yy)

To (mm/yy)

Certificates Diplomas Degrees

Award Date

(mm/yy)

C. TEACHING EXPERIENCE (if none leave blank)

Name and Location of Schools Attended (High, Technical, Vocational Schools and Colleges)

Discipline or Area Taught From (mm/yy)

To (mm/yy)

Years Months


APPLICATION FOR PROFESSIONAL STAFF CERTIFICATE (PTVT Form 3) License Application for 2017-2019

D. WORK EXPERIENCE OTHER THAN TEACHING

Name and Location of Firm Nature of Work From (mm/yy)

To (mm/yy)

Years Months

E. APPLICANT CERTIFICATION STATEMENT

I certify that the foregoing information in Sections A, B, C, and D are correct to the best of my knowledge. I have also attached the required documents.

Signature of Applicant

Date

F. ASSURANCES BY THE PRINCIPAL

All documents necessary to apply for the Professional Staff Certificate (PSC) are attached. I have reviewed and verified the applicant’s training, background, and experience. The applicant is qualified to serve as an instructor and a member of my teaching faculty.

Name of School

Signature of Principal

Date


APPLICATION FOR CONTINUING INSTRUCTORS (PTVT Form 4) License Application for 2017-2019

Complete this form and attach the following for each instructor: ❏ New licenses and certificates, if applicable




Name of School

There are changes to my personal information as noted below:

B. CHANGES TO PERSONAL INFORMATION

Mailing Address

Individual Licensure Commission on

Board License Number Expiration

Date

Phone Number

E-mail Address

Position Title Course(s) Taught

C. ASSURANCES BY THE INSTRUCTOR AND PRINCIPAL

I certify the information provided in Sections A and B are accurate to the best of my knowledge and belief. I have also attached appropriate documents if applicable.

Signature of Applicant

Date


Date


SUMMARY OF INSTRUCTORS FORM (PTVT Form 5) License Application for 2017-2019

Instructions ❏ List all instructors in alphabetical order ❏ Submit a revised list if there are changes since the last application ❏ Non-Instructional staff members must submit a current and valid tuberculosis (TB)

clearance certificate

A. NEW INSTRUCTIONAL STAFF

Legal Name (Last, First, Middle) Social Security Number xxx-xx- Course(s) Taught Teacher Certificate No.

Individual Licensure Commission

on Board License Number Expiration

Date




Date




Date




Date

B. NON-INSTRUCTIONAL STAFF (Attach TB clearance certificate)

Legal Name (Last, First, Middle) Position


SUMMARY OF INSTRUCTORS FORM (PTVT Form 5) License Application for 2017-2019

C. RETURNING STAFF (Must have Application for Professional Staff Certificate on file)

Legal Name (Last, First, Middle) Teacher Certificate No.

D. PRINCIPAL’S SIGNATURE

Name of School

Total Number of Staff


Date


PRINCIPAL CERTIFICATION FORM (PTVT Form 6) License Application for 2017-2019

Complete this form and attach the following: ❏ Documentation of Training and Experience ❏ Three (3) Letters of Verification testifying to the character, ability, and competency to operate the

school as proposed




Mailing Address

Phone Number E-mail Address

Name of School

B. CERTIFICATION

I certify that I have adequate training and experience to be principal of the school. As principal of the school, I shall be responsible for:

❏ Complying with all applicable State, County, and Department of Education policies. ❏ Providing reports and information as required by the Department of Education. ❏ Informing the Department of Education of changes in school policies, programs, facilities, tuition,

calendar, and all other matters affecting the status of the school as originally licensed. ❏ Providing all advertisements, recruitment procedures employed by representatives of the school,

published materials, and public relations activities. ❏ Directing and supervising the school’s staff and program. ❏ Assuring that all facilities comply with State and City and County requirements.


Date

C. OWNER VERIFICATION AND ASSURANCE

The above individual will serve as principal of the school. Evidence of the following is attached: ❏ Documentation of Training and Experience ❏ Three (3) Letters of Verification testifying to the character, ability, and competency to operate the

school as proposed I shall comply with all applicable State, County, and Department of Education policies.

Signature of Owner

Date


COURSE LOG AND INFORMATION FORM (PTVT Form 7)


Instructions ❏ Submit one sheet for each vocation/trade ❏ Evening classes must be approved by the Hawaii State Department of Education

A. SCHOOL INFORMATION

School Vocation/Trade

Unit measurement utilized by school: ̦ Trimester ̦ Quarter ̦ Credit ̦ Clock Hours

________________________________________ Signature of Principal

__________________________ Date

B. COURSE LOG AND INFORMATION

Course Title Instructor Time of Class Start-Finish

Class Dates Start-Finish

Length of Class

Credits or Clock Hours

Projected Enrollment

Night Course?

Yes or No


COURSE DESCRIPTION FORM (PTVT Form 8) License Application for 2017-2019

Submit one form for each course/class.


School

Vocation/Trade

B. COURSE DESCRIPTION

Course Title

Instructor(s) Projected Enrollment

Curriculum Description (What will be covered in the course/class and what equipment will be needed?)

Objectives or Standards: (What is the expectation of the student at the end of the course/class?)

Evaluation: (How will the instructor evaluate the successful completion of the course/class?)

C. LENGTH OF COURSE/CLASS

Total Weeks Total Days Number of Sessions Number of Credits/Clock Hours

First Class Date Last Class Date

D. EXPENSES FOR THE COURSE/CLASS

Tuition Books Registration Fees Other Fees

E. PRINCIPAL SIGNATURE

Signature of Principal Date


COURSE OF STUDY (PTVT Form 9) License Application for 2017-2019

Instructions ❏ Submit one sheet for each Vocation/Trade


Name of School

Vocation/Trade

Signature of Principal Date

B. COURSE OF STUDY

1 16

2 17

3 18

4 19

5 20

6 21

7 22

8 23

9 24

10 25

11 26

12 27

13 28

14 29

15 30

C. DOCUMENTATION UPON COMPLETION

Upon completion of the above, the student will receive the following: Certificate Transcript Other: __________________________


ANNUAL SUMMARY OF COURSES, FEES, AND ENROLLMENT (PTVT FORM 10)


Instructions ❏ Submit one sheet for each vocation/trade ❏ Include all Federal, State, and Private reimbursements for each class in the appropriate area (i.e. tuition, books, etc.)


School School Year __________ to __________

Vocation/Trade ________________________________________ Signature of Principal

__________________________ Date

B. COURSE LOG AND INFORMATION

Course Title

Fees Total Length of Course Number of Students

Tuition Registration Books/Supplies Other (List) Days/Sessions Weeks Credit/Clock Hours Enrolled Graduated/Completed


ANNUAL SUMMARY OF FISCAL OPERATIONS (PTVT Form 11) License Application for 2017-2019

Instructions ❏ Complete this form ❏ Attach a copy of the most recent Financial Report (audited/unaudited report)


Name of School


Date

B. INCOME AND EXPENDITURES

INCOME EXPENDITURES

Registration $ Salaries $

Student Tuition $ Rent $

Federal Reimbursement $ Instructional Materials $

State Reimbursement $ Furniture $

Private Reimbursement $ Utilities $

Books/Supplies $ Office Supplies $

Other Fees (List) Other Expenses (List)

TOTAL $ TOTAL $

C. NET PROFIT/LOSS

Subtract income total from expenditure total $


PROJECTED SUMMARY OF FISCAL OPERATIONS (PTVT Form 12) License Application for 2017-2019


Name of School


Date

B. PROJECTED INCOME AND EXPENDITURES

INCOME EXPENDITURES

Registration $ Salaries $

Student Tuition $ Rent $

Federal Reimbursement $ Instructional Materials $

State Reimbursement $ Furniture $

Private Reimbursement $ Utilities $

Books/Supplies $ Office Supplies $

Other Fees (List) Other Expenses (List)

TOTAL $ TOTAL $

C. PROJECTED NET PROFIT/LOSS

Subtract income total from expenditure total $

D. ASSETS AND DEBTS

Name of Lender Address Amount

Capital Assets (Cash) $

$

Other Assets $

$

Debts $

$


Documents

INITIAL LICENSE APPLICATION for 2017-2019 Forms/PTVT_Initial_17-19.pdfCert if icat es Diplomas Degrees A ward Dat e (mm/yy) C. TEACHING EXPERIENCE (if none l eave bl ank) Name and