Application To Remove Deficiencies Form
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PPLICATION TO
EMOVE
EFICIENCIES
– C
A
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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
Use this form to remove the Arizona Constitution, United States Constitution, and/or Fingerprint Clearance card deficiency.
Submit the following:
Checklist:
□
Completed Application.
o Answer EVERY Background Question, sign and date the application.
o If you answer “Yes” to any Background questions, you MUST submit a completed
Explanation of Incident
form for each incident, even if the incident was previously disclosed.
□
A photocopy of your valid Arizona Department of Public Safety Identity Verified Prints (IVP) fingerprint card.
□
If you are applying to remove the Arizona and/or United States constitution deficiency, submit official transcript(s) or a
photocopy of the passing AEPA Constitutions of the United States and Arizona exam score report.
□
A check or money order for $20. Credit card payments may be accepted at the Phoenix Certification office.
SECTION 1: PERSONAL INFORMATION (TYPE OR PRINT IN BLUE OR BLACK INK)
Social Security Number:
________-_______-___________
Date of Birth:
_____/_____/________
Gender:
M / F
(For identification purposes only)
________________________________________________________________________________________________
Full Legal Name:
Last
First
Middle
Mailing Address:
________________________________________________________________________________________________
Street Number or P.O. Box
City
State
Zip
(______) ______-________
_________________________________________
Telephone:
Email Address:
Ethnicity:
____American Indian or Alaskan Native
____Black or African-American (Not-Hispanic)
____White (Not-Hispanic)
____Asian or Pacific Islander
____Hispanic or Latino
____Other
(Gender and Ethnicity are requested for federal reporting purposes only)
PLEASE PLACE AN “X” ON THE LINE NEXT TO THE DEFICIENCIES YOU ARE REMOVING:
____ Arizona Constitution ____U.S. Constitution ____Valid Arizona Fingerprint Clearance Card (plastic)
____ I have enclosed my official transcripts.
____ I have requested my official transcripts be mailed to your department from the following College(s) and/or Universities:
__________________________________________________
____ I have enclosed copies of official Arizona Constitution and/or U.S. Constitution test results
____ I have enclosed a photocopy of my valid Arizona Department of Public Safety Identity Verified Prints (AZDPS IVP)
Fingerprint Clearance Card (plastic)
** 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. 6-29-2016)
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