Application To Extend An Interim Administrative Certificate Form
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PPLICATION TO
E
I
A
C
XTEND AN
NTERIM
DMINISTRATIVE
ERTIFICATE
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U
RIZONA
EPARTMENT OF
DUCATION
ERTIFICATION
NIT
Mailing Address: P.O. Box 6490, Phoenix, AZ 85005-6490 Telephone: (602) 542-4367
Interim Administrative certificates are issued in the areas of supervisor, principal and superintendent. It entitles the holder to perform the
duties described under the specific certificate. The certificate is valid for one year from the date of issuance and may be extended yearly
for no more than two consecutive years. The candidate must be enrolled in an Arizona State Board approved alternative path to
administrator certification program, or an Arizona State Board approved administrator preparation program. Verification of Structured
English Immersion (SEI) training is required for initial issuance. An individual is not eligible to hold the interim administrative certificate
more than once in a five-year period.
G
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:
ENERAL
NSTRUCTIONS AND
NFORMATION
Please submit the following:
A. A photocopy of your valid Arizona Department of Public Safety Identity Verified Prints (IVP) fingerprint card.
B. A completed Application to Extend an Interim Administrative Certificate. There is NO FEE to extend the certificate.
C. Letter of verification, signed by the dean or department chair of a college of education, indicating the certificate
holder is making adequate progress in the Arizona State Board approved alternative path to administrator
certification program, or an Arizona State Board approved administrator preparation program.
Official transcript(s) documenting the required coursework must accompany the letter.
D. A letter of verification indicating the holder of the interim certificate shall be under the direct supervision of the
appropriate Arizona certified district administrator or the appropriate County School Superintendent.
Please refer to our website at or your evaluation for any other specific
requirements.
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Print in blue or black ink.
ECTION
ERSONAL
NFORMATION
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)
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ECTION
ERTIFICATION
YPE
INTERIM ADMINISTRATIVE CERTIFICATES (PreK-12):
I am extending my:
___ INTERIM PRINCIPAL, PreK-12
___ INTERIM SUPERINTENDENT, PreK-12
___ INTERIM SUPERVISOR, PreK-12
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EQUIREMENTS MAY BE SUBJECT TO CHANGE AND ARE FULLY REFERENCED IN THE
RIZONA
EVISED
TATUTES AND
DMINISTRATIVE
ODE
Version 3.0 (Rev. 2/18/2014)
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ERTIFICATION
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