Application To Extend Reciprocal Certificate Form (Per State Board Rule Change)

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A
E
R
C
PPLICATION TO
XTEND
ECIPROCAL
ERTIFICATE
(
S
B
R
C
)
PER
TATE
OARD
ULE
HANGE
– C
A
D
E
U
RIZONA
EPARTMENT OF
DUCATION
ERTIFICATION
NIT
Mailing Address: P.O. Box 6490, Phoenix, AZ 85005-6490 • Telephone: (602) 542-4367
GENERAL INSTRUCTIONS AND INFORMATION
Effective May 4, 2015, the State Board of Education approved a rule change which allows Reciprocal teaching
and Reciprocal administrative certificate holders to meet the requirements of passing the required Arizona
educator exams and completing Structured English Immersion endorsement training within three years instead of
one year. Educators who currently hold a one-year Reciprocal Teaching certificate or a one year Reciprocal
Administrative certificate may use this form to apply to extend their certificate per the State Board rule change.
Submit the following:
Checklist:
Completed Application for Temporary Extension per Legislative Change
o Answer EVERY Criminal History Question, sign and date the application.
o If you answer “Yes” to any Criminal History questions, you MUST submit a completed
Explanation of
Incident
form.
A photocopy of your valid Arizona Department of Public Safety Identity Verified Prints (IVP) fingerprint card
(plastic).
A check or money order for the appropriate fee. The fee is $20 per certificate to be extended. Note: Certification fees
will not be refunded even if you do not qualify for the requested service.
If you are certified in History, Political Science/American Government, or Middle Grade Social Studies and have an
Arizona and/or US constitution deficiency you MUST submit official transcript(s) or exam score report(s) to satisfy
these deficiencies and qualify for the extension.
SECTION 1: PERSONAL INFORMATION (TYPE OR PRINT IN BLUE OR BLACK INK)
________-_______-___________
_____/_____/________
M / F
Social Security Number:
Date of Birth:
Gender:
(For identification purposes only)
Full Legal Name:
________________________________________________________________________________________________
Last
First
Middle
________________________________________________________________________________________________
Mailing Address:
Street Number or P.O. Box
City
State
Zip
Telephone:
(______) ______-________
Email Address:
_________________________________________
____American Indian or Alaskan Native
____Black or African-American (Not-Hispanic)
____White (Not-Hispanic)
Ethnicity:
____Asian or Pacific Islander
____Hispanic or Latino
____Other
(Gender and Ethnicity are requested for federal reporting purposes only)
SECTION 2: CERTIFICATE(S) TO EXTEND
I am requesting a temporary extension of the following Reciprocal certificate(s) due to the State Board/
legislative rule changes.
I understand that if I am granted an extension I must satisfy ALL deficiency
requirements by the expiration date of my extended certificate in order to maintain my qualification to teach in
Arizona public schools.
__ Reciprocal Provisional Arts Education
__ Reciprocal Provisional Elementary
__ Reciprocal Provisional Special
($20)
($20)
Education ($20 each)
__ Reciprocal Provisional Early Childhood
__Reciprocal Provisional Secondary
__ Reciprocal Principal ($20)
($20)
($20)
__ Reciprocal Superintendent ($20)
__ Reciprocal Supervisor ($20)
** R
A
R
S
A
C
. **
EQUIREMENTS MAY BE SUBJECT TO CHANGE AND ARE FULLY REFERENCED IN THE
RIZONA
EVISED
TATUTES AND
DMINISTRATIVE
ODE
Version 1 (Rev. 4-30-2015)
.A
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.G
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WWW
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OV
DUCATOR
ERTIFICATION

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