School Psychologist (093) Certificate Page 6
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11The following information should be provided by the person completing this form.
My name and contact information is:
Name: (print clearly):
________________________________________________
Address:
________________________________________________
________________________________________________
Phone #:
________________________________________________
I declare under penalty for perjury in the law that the following are my academic and professional credentials:
Highest Degree _____________ Date received _______________ Institution _____________________
School psychology:
Certified:
No ___ Yes ___ Certification Title: ______________________ State: _____________
Licensed:
No ___ Yes ___ State: _________ License number: ___________________________
NCSP:
No ___ Yes ___
Member:
NASP ____
APA ____
State Association: ______________________________
Date (of the endorsement): _________________________
The foregoing statements are true and of my own personal knowledge where specifically indicated, and otherwise
the statements are true to the best of my knowledge, information and belief, and where based on information and
belief, I believe the statements are true.
I recommend (name) ________________________, D.O.B. ________________to the Maine Department of
Education for certification as a School Psychologist.
Name: _____________________________________________________________
Notarized signature: __________________________________________________
State of: _____________________
County of:___________________
The Affiant, _________________________________, appeared before me this day (date ) ________ and
acknowledged the foregoing statements are true and of his / her own personal knowledge where specifically
indicated, and otherwise that the statements are true to the best of his / her knowledge, information and belief, and
where based on information and belief, he / she believes the statements are true.
Notary Public/Attorney : ________________________________________________________
My Commission Expires: _________________ Bar Number: ___________________________
(date)
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