Explanation Of Incident - Arizona Department Of Education Page 2
ADVERTISEMENT
1
2E
I
XPLANATION OF
NCIDENT
A
D
E
– C
U
RIZONA
EPARTMENT OF
DUCATION
ERTIFICATION
NIT
Mailing Address: P.O. Box 6490, Phoenix, AZ 85005-6490
Telephone: (602) 542-4367
If you have answered "Yes" to either of the following questions:
1. Have you ever had any professional certificate or license, revoked or suspended?
2. Have you ever received a reprimand or other disciplinary action involving any professional
certification or license?
Please provide the following information. Note: If there was more than one action against your professional
certificate(s) or license (s), please attach a separate explanation form for each action.
Social Security Number:
-
-
Full Legal Name:
Last
First
Middle
Type of License/Certification: ___________________________________________________
Type of Discipline/Reprimand: ________________________Length of Disciplinary period:_________________
Agency which issued Discipline: _________________Date of issuance: _______________State: __________
Description of Circumstances:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
_____________________________________________________________________________
Disposition/Current Status of the Disciplinary Action:
___________________________________________________________________________________________
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 2.1 (Rev.7-30-2016)
.A
E
.G
/E
-C
/
Page 2 of 2
WWW
Z
D
OV
DUCATOR
ERTIFICATION
ADVERTISEMENT
0 votes
Related Articles
Related forms
Arizona Form 74 - Report Of Personal Representative Of Decedent - Arizona Department Of Revenue
Financial
Arizona Form 819nr - Nonresident Distributor's Monthly Return Of Cigars And Tobacco Products Sold (for Nonresident Licensed Distributors) - Arizona Department Of Revenue
Financial
Arizona Form 800-20 - Cigarette Distributor's Monthly Return - Arizona Department Of Revenue
Financial
Arizona Form 800-25 - Cigarette Distributor's Monthly Return - Arizona Department Of Revenue
Financial
Arizona Form 800nr - Cigarette Distributor's Monthly Return For Nonresident Licensed Distributors - Arizona Department Of Revenue
Financial
Related Categories
Parent category: Legal