Application To Extend Provisional Teaching, Secondary Stem, Or Administrative Certificate With Structured English Immersion (Sei) Endorsement Deficiency Form Page 2
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1
2A
E
P
T
, S
STEM,
PPLICATION TO
XTEND
ROVISIONAL
EACHING
ECONDARY
OR
A
C
S
E
I
(SEI)
DMINISTRATIVE
ERTIFICATE WITH
TRUCTURED
NGLISH
MMERSION
E
D
NDORSEMENT
EFICIENCY
– C
A
D
E
U
RIZONA
EPARTMENT OF
DUCATION
ERTIFICATION
NIT
SECTION 3: CRIMINAL HISTORY
Answer EVERY question, Sign and Date:
ATTENTION: If “YES” is indicated for any of the following questions, please attach a full explanation
to this application, a statement must be provided with each application.
Have you ever had any professional certificate or license, revoked or suspended?
1. YES__ NO__
2. YES__ NO__
Have you ever received a reprimand or other disciplinary 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. Have you ever been arrested for any of the following offenses in this state or similar offenses in another
jurisdiction?
Second-degree murder
YES__ NO__
a
Continuous sexual abuse of a child
YES__ NO__
n
YES__ NO__
Aggravated assault resulting
b
YES__ NO__
Attempted first-degree murder
o
in serious physical injury or
Any other dangerous crime against
YES__ NO__
p
involving the discharge, use
children as defined in section 13-
or threatening exhibition of a
604.01
deadly weapon or dangerous
YES__ NO__
Any of the above listed offenses if
q
instrument against a minor
committed as a reparatory offense as
under fifteen years of age
described in section 13-1001
YES__ NO__
Sexual assault
c
YES__ NO__
Any offense causing you to register
r
YES__ NO__
Molestation of a child
d
as a sex offender
Sexual conduct with a minor
YES__ NO__
e
YES__ NO__
First-degree murder
s
YES__ NO__
Commercial sexual
f
Armed Robbery
YES__ NO__
t
exploitation of a minor
YES__ NO__
Incest
u
YES__ NO__
Sexual exploitation of a minor
g
YES__ NO__
Exploitation of minors involving
v
Child abuse
YES__ NO__
h
drug offenses
Kidnapping
YES__ NO__
i
YES__ NO__
Sexual abuse of a
w
YES__ NO__
Sexual abuse of a minor
j
vulnerable adult
Taking a child for the purpose
YES__ NO__
k
YES__ NO__
Sexual exploitation of a vulnerable
x
of prostitution as prescribed in
adult
section 13-3206
Commercial sexual exploitation of a
YES__ NO__
y
YES__ NO__
Child prostitution as
l
vulnerable adult
prescribed in section 13-3212
Abuse of a vulnerable adult
YES__ NO__
z
Involving or using minors in
YES__ NO__
m
YES__ NO__
Molestation of a vulnerable adult
aa
drug offenses
Neglect of a vulnerable adult
YES__ NO__
bb
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
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. 9-28-2015)
.A
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