Renewal Of Speech-Language Pathologist, Prekindergarten-12 And Speech-Language Technician, Prekindergarten-12 Certificate Form printable pdf download

PPLICATION

ENEWAL OF

-L

, P

-12

PEECH

ANGUAGE

ATHOLOGIST

REKINDERGARTEN

AND

-L

, P

-12 C

PEECH

ANGUAGE

ECHNICIAN

REKINDERGARTEN

ERTIFICATE

– C

RIZONA

EPARTMENT OF

DUCATION

ERTIFICATION

NIT

Mailing Address:

P.O. Box 6490, Phoenix, AZ 85005-6490

Telephone: (602) 542-4367

- Submit the following:

ENERAL

NSTRUCTIONS AND

NFORMATION

A. A photocopy of your valid Arizona Department of Public Safety Identity Verified Print (IVP) fingerprint card (plastic).

B. Application for Renewal of Speech-Language Pathologist and Speech-Language Technician Certificate form completed

along with your payment. Acceptable forms of payment are personal check, money order, or cashier's check made payable to

the Arizona Department of Education. Cash will not be accepted. Fees are not refundable.

C. Verification of the required clock hours or semester hours of professional development completed during the valid period of the

certificate to be renewed. See Section 4 on Page 2 for the required hours.

1: P

ECTION

ERSONAL

NFORMATION

Please use blue or black ink.

Social Security Number: _________-______-____________

Date of Birth: ____/____/________

Gender: M / F

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

–

2: C

ECTION

ERTIFICATES AND FEES

Please select the certificate(s) to be renewed:

___ SPEECH-LANGUAGE PATHOLOGIST, PREKINDERGARTEN-12 ………….….. $20

___ SPEECH-LANGUAGE TECHNICIAN, PREKINDERGARTEN-12 ………….….. $20

If “YES” is indicated for any of the following questions, you must attach an Explanation of

ATTENTION:

Incident form to your application before it can be processed. You may download the form

at:

3: C

- Answer EVERY question, sign and date. Attach Explanation of Incident,

ECTION

RIMINAL

ISTORY

if required.

1.  YES__ NO__ Have you ever had any professional certificate or license,

2.  YES__ NO__ Have you ever received a reprimand or other disciplinary

revoked or suspended?

action involving any professional certification or license?

3.  YES__ NO__ Have you ever been convicted of any felony offense?

4.  YES__ NO__ Have you ever been arrested for any offense for which

you were fingerprinted?

5.  (Answer every

Have you ever been arrested for any of the following offenses

(continued) Have you ever been arrested for any of

question.)

in this state or similar offenses in another jurisdiction?

question.)

the following offenses in this state or similar

offenses in another jurisdiction?

 YES__ NO__ Second-degree murder

 YES__ NO__

Continuous sexual abuse of a child

 YES__ NO__ Aggravated assault resulting in serious physical injury or

 YES__ NO__

Attempted first-degree murder

 YES__ NO__

involving the discharge, use or threatening exhibition of a

Any other dangerous crime against children as defined

deadly weapon or dangerous instrument against a minor

in section A.R.S. § 13-604.01

 YES__ NO__

under fifteen years of age

Any of the above listed offenses if committed as a

 YES__ NO__ Sexual assault

reparatory offense as described in A.R.S. 13-1001

 YES__ NO__ Molestation of a child

 YES__ NO__

Any offense causing you to register as a sex offender

 YES__ NO__ Sexual conduct with a minor

 YES__ NO__

First-degree murder

 YES__ NO__ Commercial sexual exploitation of a minor

 YES__ NO__

Armed Robbery

 YES__ NO__ Sexual exploitation of a minor

 YES__ NO__

Incest

 YES__ NO__ Child abuse

 YES__ NO__

Exploitation of minors involving drug offenses

 YES__ NO__ Kidnapping

 YES__ NO__

Sexual abuse of a vulnerable adult

 YES__ NO__ Sexual abuse of a minor

 YES__ NO__

Sexual exploitation of a vulnerable adult

 YES__ NO__ Taking a child for the purpose of prostitution as prescribed in

 YES__ NO__

Commercial sexual exploitation of a vulnerable adult

 YES__ NO__

section A.R.S. § 13-3206

Abuse of a vulnerable adult

 YES__ NO__ Child prostitution as prescribed in section ARS § 13-3212

 YES__ NO__

Molestation of a vulnerable adult

 YES__ NO__ Involving or using minors in drug offenses

 YES__ NO__

Neglect of a vulnerable adult

I understand that pursuant to ARS § 15-534, any person who makes a false statement, representation or certification in any application for certification is

guilty of a misdemeanor offense. I swear or affirm that the foregoing information completed by me, or submitted by me for certification purposes is, to the best

of my knowledge, true and correct. Furthermore, should any part or all of the information herein provided prove to be false, I recognize that it shall be just

cause for revocation, suspension, or other disciplinary action against any certificate issued to me by the Arizona Department of Education.

____________________________________________ _____________

Applicant’s Signature

Date

** R

. **

EQUIREMENTS MAY BE SUBJECT TO CHANGE AND ARE FULLY REFERENCED IN THE

RIZONA

EVISED

TATUTES AND

DMINISTRATIVE

ODE