Application For Wyoming Certification Of Teachers, Administrators, And Other Personnel (Page 5 of 8) in pdf

Application For Wyoming Certification Of Teachers, Administrators, And Other Personnel Page 5

Have you ever been dismissed or discharged, or have you resigned in order to avoid discipline or discharge

by any employer?

Yes_____ No_____

If so, then state on a separate sheet of paper, the name, address, and telephone number of employer; the

nature of the allegations; and the final disposition.

I hereby attest that all information I am submitting is true and complete to the best of my knowledge. I

understand that any intentional misrepresentation of facts may result in denial of or annulment of a certificate

and that falsification of statements on and with this attestation may be punishable by law. I authorize law

enforcement agencies, courts, health care providers, and custodians of Administrative Records to disclose to the

Wyoming Professional Teaching Standards Board information from the records in their possession. I further

authorize these agencies to permit the examination and furnish copies of all records and other reports in their

possession and control. I understand that the specific type of information to be disclosed includes reports of any

kind contained in my record file, regardless of their origin.

__________________________________________________

Signature of the applicant

(to be signed in the presence of a Notary Public)

County

State of ____________________________

Subscribed and sworn to before me this ________day of____________________, 20_____ My commission expires

_____________________

Witness my hand and official seal:

Notary_______________________________________________________________

Address______________________________________________________________

Seal

City, State, Zip________________________________________________________

PTSB, 307-777-7291

2300 Capitol Avenue

Cheyenne, WY 82002

Application For Wyoming Certification Of Teachers, Administrators, And Other Personnel Page 5