Form Spi/cert 4020e - Verification Of Program Completion And Character
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1OFFICE OF SUPERINTENDENT OF PUBLIC INSTRUCTION
Professional Certification
Old Capitol Building, PO BOX 47200
OLYMPIA WA 98504-7200
(360) 725-6400 TTY (360) 664-3631
Web Site: http:/ /
E-Mail: cert@k12.wa.us
VERIFICATION OF PROGRAM
COMPLETION AND CHARACTER
ALL SECTIONS must be completed. Send it to the institution/organization* where you completed your teacher preparation and certification
program. This form, when returned to you, is to be included with your application packet.
*If you were trained outside the U.S. and Canada, use Form SPI 4030 instead of this form.
SECTION A
TO BE COMPLETED BY APPLICANT
1.
NAME
LAST
FIRST
MIDDLE
MAIDEN/FORMER NAME
2.
ADDRESS
3.
DATE OF BIRTH
CITY/STATE/ZIP
4.
SOCIAL SECURITY NO. (OPTIONAL)
5.
TELEPHONE:
6.
E-MAIL
(
)
(
)
BUSINESS
HOME
SECTION B
TO BE COMPLETED BY COLLEGE/UNIVERSITY
The above named is an applicant for teacher certification in Washington State. To be valid, this form must be signed by the program director of the
organization or the dean of the college or school of education, the certification officer, the chair of the education department, or the dean’s designee at
the institution where the applicant completed his/her teacher preparation and certification program. A stamped signature must be initialed by the person
using the stamp. RETURN THIS FORM TO THE APPLICANT.
A.
Has this applicant completed your state-approved teacher education program?
A.
NO
YES
Date of student
teaching.
Date of program enrollment.
Date of program completion.
If no, what were the deficiencies?
B.
Was he/she eligible for certification in your state at the completion of the teacher preparation program?
B.
NO
YES
If no, what were the deficiencies?
C.
C.
Did the applicant complete his/her practicum/student teaching in a Washington school?
NO
YES
For D & E, please note: In order to qualify for an endorsement area, the applicant must have completed an approved program in that
area. Each endorsement program must include coursework in methodology for that content area and completion of a supervised,
classroom-based field experience/internship that includes instruction in that content area.
D.
Area in which applicant is recommended for certification. Please indicate area and grade level(s).
AREA
GRADE LEVEL(S)
E.
Other approved content area/endorse-
AREA
GRADE LEVEL(S)
ment programs that applicant has
completed:
Do you have knowledge that the applicant has been arrested, charged, or convicted of any crime or has a history of any serious
F.
behavioral problems?
List any reason you know of why this applicant should not be certified in Washington.
YES
NO
NAME OF INSTITUTION/ORGANIZATION
DATE
By signing this form I
ADDRESS
attest that the above
information is true and
CITY/STATE/ZIP
accurate to the best of
my knowledge.
TELEPHONE
E-MAIL
(
)
NAME (PRINTED) AND TITLE (Program Director of Organization/Chairperson/Dean of Education Department/
SIGNATURE
Certification Office)
FORM SPI/CERT 4020E (Rev. 2/12)
RETURN COMPLETED FORM TO THE APPLICANT
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