Wednesday, December 07, 2022 05:28 PM

HTSB Forms

The following supplemental documents are the forms needed for applications. Please apply through your HTSB online account before submitting these forms. Completed forms should be uploaded to the Documents tab of your HTSB account.

HTSB Forms Download PDF Forms

HTSB Form LA3009:

To verify completion of an Educator Preparation Program (EPP)  that is not based in Hawaii.  This includes programs based in other states, District of Columbia, and US territories of Guam, Commonwealth of the Northern Mariana Islands, U.S. Virgin Islands, and Puerto Rico.

Applications from individuals who completed an out-of-state teacher preparation program must be accompanied by a copy of a valid unrevoked license/certificate/credential from another jurisdiction.

Individuals who completed a Hawaii EPP do not need to submit this form as their program will be verified electronically by the EPP.

LA3009-Revised-9-19-2022-Fillable
  • (Revised form required to be used for all new applications submitted after 9/19/22)
  Note: Effective Immediately, see board adopted requirements for any individual seeking a Hawaii license who has completed an out-of-state teacher preparation program and has not acquired a full license or certificate from a U.S. state, District of Columbia, or U.S. territory.
  • All documentation is required to support the LA3009

HTSB Form EX1000:

To verify experience to qualify for a Standard or Advanced License, or to Add a Field to a License.

Hawaii DOE teachers do not need to submit this form as their experience will be verified electronically by the DOE.

EX-1000-Revised-9-19-2022-Experience Form Fillable

(Revised form required to be used for all new applications submitted after 9/19/22)

Note: According to Hawaii Administrative Rules (HAR) 2014, experience is defined as contracted full-time teaching experience in a P-12 setting in Hawaii or another state

HTSB Form OS3009:

To verify a license from another state.  This includes professional educator licenses issued by other states and US territories of Guam, Commonwealth of the Northern Mariana Islands, U.S. Virgin Islands, and Puerto Rico.  The other jurisdiction may also verify your basic skills and content knowledge on this form.

OS3009 Agency Confirmation of Licensure

HTSB Form Trade or Industry EX:

This form is used to verify trade or industry experience for a Career and Technical Education field or Computer Science field.

CTE Trade or Industry Experience Verification
HTSB Form RA4010:

Non-Hawaii public school teachers use this form to verify employment for license renewal.  Hawaii DOE and Charter School teachers will have their experience verified electronically.

RA4010 Verification-of-Experience-Renewal Fillable

HTSB Form RA5010:

Verification of Satisfying Hawaii Teacher Performance Standards:  This form helps you record how you verify that you meet the teaching standards.  Hawaii DOE teachers who had a satisfactory evaluation during the term of the license they are renewing will be verified electronically by the DOE.

RA5010 Teacher Standards for Renewal
HTSB Form RA5010 C:

Verification of Satisfying Hawaii Counselor Performance Standards:  This form helps you record how you verify that you meet the counseling standards.  Hawaii DOE counselors who had a satisfactory evaluation during the term of the license they are renewing will be verified electronically by the DOE.

RA5010 Counselor Standards for Renewal

HTSB Form RA5010 L:

Verification of Satisfying Hawaii Librarian Performance Standards:  This form helps you record how you verify that you meet the librarian standards.  Hawaii DOE librarians who had a satisfactory evaluation during the term of the license they are renewing will be verified electronically by the DOE.

RA5010L School Librarian Renewal Standards Verification

HTSB Form Voluntary Removal of License Field:

This form is used to request that a field is removed from your current license.  Once removed a field can only be added by meeting the requirements in effect at that time.

Request to Remove License Field

HTSB Form Voluntary Surrender of Hawaii Teaching License, Permit, or Certificate

This form is used to request the voluntary surrender of an active teaching license, permit, or certificate for a variety of reasons. Please be sure to complete all fields on the form.
Request to Surrender License Form-Fillable

RA6010 T

This form is for non-Hawaii DOE teachers to give their administrators to verify they meet the Hawaii Teacher Performance Standards on their most recent evaluation.

  RA6010T Performance Standards Worksheet  for Teachers  

RA6010 C

This form is for non-Hawaii DOE counselors to give their administrators to verify they meet the Hawaii Counselor Performance Standards on their most recent evaluation.

  RA6010C Performance Standards Worksheet  for Counselors

RA6010 L

This form is for non-Hawaii DOE librarians to give their administrators to verify they meet the Hawaii Librarian Performance Standards on their most recent evaluation.

  RA6010L Performance Standards Worksheet  for Librarians

TL7010

This form is for Hawaii DOE Teacher Leaders who need their administrators to verify teacher leader experience.
TL7010 Teacher Leader Verification Form

Formal Notary Request Form

This form is to formally request the notarization of a Hawaii License
Formal Notary Request Form