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2014 Employer Assurance Form

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Georgia PSC Employer Assurance Form –

Revised March 2014

200 Piedmont Avenue SW, Suite 1702, Atlanta, GA 30334-9032

Fax: 404-232-2560 |

Please Use Dark Ink or Type

1. Applicant Information:

Title

Last Name

Mr.

Ms.

Dr.

First Name

Middle Name

Social Security Number or GaPSC Certification ID

Date of Birth (MM/DD/YY)

Sections 2, 3, & 4 must be completed by the employer.

2. Employment Verification:

In submitting this form I certify that the applicant listed above is/will be employed as a full-time educator

by the Georgia school system, school, or agency listed below and verify that the required

background checks have been completed and are on file in the school/system/agency central office.

Employment is in the certification field of :

Employment in this certificate field began on:

(MM/DD/YY)

3. Transaction Request:

I am requesting the following transaction(s) on behalf of the applicant listed above (check all that apply):

First GA certificate (issue Non-Renewable if appropriate)

Conversion of an existing certificate

Renewal

Waiver

Upgrade

Permit (Initial/Renewal)

Addition of a renewable field

Issuance of an International Exchange Certificate

Addition of the following Non-Renewable or Supplemental Induction field to an existing certificate:

Field Code:

(see reverse)

* In requesting a Non-Renewable certificate, the system/agency affirms that the applicant is the best qualified applicant available for the certificate field

requested and understands that requirements specified by the GaPSC must be completed during the validity of the Non-Renewable certificate.

Other unlisted transaction (please specify):

4. Employer Information:

Name of Superintendent or authorized Central Office Designee (print/type)

Signature

Title

Date

Phone Number

Email Address

Georgia School System/Agency/Private Institution