Louisiana Department Of Education Professional Conduct Form printable pdf download

Louisiana Department Of Education Professional Conduct Form

LOUISIANA DEPARTMENT OF EDUCATION

CERTIFICATION, PREPARATION, and RECRUITMENT

PLEASE TYPE OR PRINT IN INK

PROFESSIONAL CONDUCT FORM

(All questions must be answered)

NAME OF APPLICANT: (Including, First, Middle, and Married)

Social Security Number:

________ - ______ -_______

ADDRESS:

DATE OF BIRTH:

Please Check

Each Question must be answered:

YES

1. Have you ever had any professional license/certificate denied, suspended, revoked, or

voluntarily surrendered?

If YES, in what state?____________________________

2. Are you currently being reviewed or investigated for purposes of such action as stated in #1

or is such action pending?

If YES, in what state?_____________________________

3. Have you ever been convicted of any felony offense, been found guilty or entered a plea of

nolo contendere (no contest), even if adjudication was withheld?

If yes, please provide the following information:

Specify the Offense: ____________________ Date of Offense: _____________

State and Parish/County of Conviction: _______________________________

Judicial District of Court of Conviction: _________________________________

4. Have you ever been convicted of a misdemeanor offense that involves any of the following:

a. Sexual or physical abuse of a minor child or other illegal conduct with a minor child.

b. The possession, use, or distribution of any illegal drug as defined by Louisiana or federal

law.

5. Have you ever been granted a pardon or expungement for any offense as stated in #3 or

#4?

If you answered “YES” to any questions, #1 through #5, you must provide court certified copies of all documents

and proceedings, civil records of Federal, State and/or District School Board actions, or other relevant documents

that provide full disclosure of the nature and circumstances of EACH separate incident in your application packet.

I affirm and declare that all information given by me in the responses to items #1 through #5 above is true, and

correct, and complete to the best of my knowledge. I understand that any misrepresentation of facts, by omission

or addition, may result in criminal prosecution and/or the denial or revocation of my teacher certificate.

SIGNATURE OF APPLICANT:

DATE:

Louisiana Department Of Education Professional Conduct Form