Georgia Psc Approved Program Completion Form
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2Georgia PSC Approved Program Completion Form –
Revised March 2014
200 Piedmont Avenue SW, Suite 1702, Atlanta, GA 30334-9032
Fax: 404-232-2560 |
See Reverse for Instructions - Please Use Dark Ink or Type
1. Applicant Information:
Title
Last Name
Mr.
Ms.
Dr.
First Name
Middle Name
Social Security Number or GaPSC Certification ID
Date of Birth (MM/DD/YY)
/
/
2. Certification Official Section:
Program Completion (please check one):
I certify that the applicant listed above has completed all current requirements for the approved preparation program for certification as
an educator. The preparation program was state-approved in the field(s) and at the level which the applicant completed.
I certify that the applicant listed above has NOT completed all current requirements for the approved preparation program for certification
as an educator.
Degree Information (please check one):
The certification program the applicant completed led to the following degree:
The program the applicant completed was for certification only and no degree was awarded.
Student Teaching Internship Information:
The applicant completed student teaching in the following state:
Date of completion:
Name and Certification ID of Supervising Teacher:
(for student teaching completed in GA only)
Field Code
CERTIFICATION / ENDORSEMENT FIELD(S)
(See Reverse)
Program Information:
/
/
/
/
Program Start Date:
Program End Date:
State:
MM/DD/YY
MM/DD/YY
Accreditation/Approval Status
:
(check all that apply)
Regional
State
GaPSC
NCATE/TEAC/CAEP
NASP
ASHA
Other: _____________________
Name of Certification Officer (print/type)
Signature
Title
Date
Phone Number
Email Address
Affix School Seal Here
Name of Institution
Mailing Address
City, State, Zip
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