Form Pde 338 R-4 - Request For Appeal - Pennsylvania Department Of Education Page 2
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pennsylvania
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DEPARTMENT OF EDUCATION
Revised October 2017
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Request for Appeal: ACT 48/ACT 45
Form PDE 338 R-4
APPLICANTS: Please note the following information in regard to your Social Security Number (SSN)
DATA REQUIRED BY THE FEDERAL PRIVACY ACT (5 U.S.C. Section 552a note)
AUTHORITY: 24 P.S. § 1224.
PRINCIPAL PURPOSE(S): To be used for maintenance of continuing education records of all certificated individuals.
ROUTINE USES: Used by the Pennsylvania Department of Education for the identification, evaluation, registration, and maintenance of
continuing education records for certificated individuals.
DISCLOSURE: Voluntary. Withholding requested SSN may result in a delay of the initiation of the appeal process while the individual’s
identity is verified and records are located.
Last Name:
First Name:
MI:
Social Security Number:
Date of Birth:
Sex:
M
F
Street Address:
City, State and Zip Code:
Home Phone:
Daytime Phone:
Chronologically print former name(s) beginning with the most recent:
Last Name:
First Name:
MI:
Last Name:
First Name:
MI:
Reason for Appeal (Check One)
Discrepancy in (credit/hours) reported to the Department. (see back for details)
Other:
Criteria for Appeal: Please submit three copies of the following documentation for your appeal to be considered:
a. Your teaching certificate
b. PDE Notice of Inactive Certification
c. Brief statement explaining your reason(s) for appeal
d. Any necessary documentation to support your appeal
The Division of Planning must receive all appeals within 30 days of the date of the PDE Notice of Inactive Certification.
Applicant Statement:
I certify that the information provided in this application, including all statements, transcripts and documentation are
correct and true. I understand that the falsification of any statement or document may be result in the revocation of my
Pennsylvania certificate.
Print Name
Signature of Applicant
Date
PDE USE ONLY
Approved
Denied
Date
Initials
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