State Form 36 - Tuition Reimbursement

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Office of Professional Preparation
FOR EMPLOYING COUNTY OR INSTITUTION USE ONLY
FOR OFFICIAL WVDE USE ONLY
Building 6, Room 252
Date Received by the WVDE
1900 Kanawha Boulevard East
Date of County Receipt: ______________________________________
Charleston, WV 25305
Phone: 304-558-7010
Date Received by Institution of Higher Education: __________________
Part 1 -Applicant Information
Part 2 -Disclosure of Background Information
If you answer yes to any question
below,
SUBMIT
with
your
_____________________________
_______________________
_____________
___________________
application a complete narrative.
Social Security Number
Birth Date (MM-DD-YYYY)
Gender (M or F)
US Citizen ( YES or NO)
Include dates, locations, school
s y s t e m s ,
a n d
a n y
o t h e r
____________________________________
________________________________________ ___________
________________________
appropriate information.
Last Name
First Name
MI
Previous Last Name (Maiden)
1) Have you ever had adverse
_____________________________________________________
____________________________________
______
________________
a ction
taken
again st
any
Street Address
City
State
Zip Code
application, certificate, or license
in any state? Adverse action in-
___________________________________
___________________________________
___________________________________________
cludes the following:
letter of
Primary Phone
Secondary Phone
E-Mail
warning, reprimand, denial, sus-
pension,
revocation,
voluntary
List the institutions from which you’ve earned a degree.
Are you currently employed by a
Do you currently hold a License
surrender or cancellation.
West Virginia School System?
to work in the public schools of
2) Have you ever been disciplined,
College/University
Degree
Date
West Virginia?
reprimanded,
suspended,
or
Yes
No
Yes
No
discharged from any employment
because
of
allegations
of
If YES, please indicate the
Do you currently hold a License
misconduct?
school system:
to work in the public schools of
another state?
3) Have you ever resigned, en-
__________________________
Yes
No
t e r e d
i n t o
a
s e t t l e m e n t
agreement,
or
otherwise
left
employment as a result of alleged
Part 3—Applicant’s Signature
misconduct?
I swear or affirm under the penalty of false swearing that all information provided in or with this application is true, correct, and complete to the best of
4) Is any action now pending
my knowledge. I understand that any false statements, misrepresentations, or omissions of fact in or with this application are grounds for denial,
against you for alleged misconduct
suspension, or revocation of the license(s) that I am seeking or currently hold.
in any school district, court, or
before
any
educator
licensing
_____________________________________________
_________________________
agency?
Signature of Applicant
Date
5) Have you ever been charged
with or convicted with or under
The following forms are included with this application:
indictment for a felony? *
______________
______________
______________
______________
______________
______________
______________
Form #
Form #
Form #
Form #
Form #
Form #
Form #
6) Have you ever been charged
You must include a $15.00 Processing Fee with EACH FORM attached. (Excluding Forms 4B, 7, 35, 36, 37, V10, V16)
w i t h
o r
c o n v i c t e d
o f
a
Any applicant required to submit a fingerprint card is required to pay an additional $34.00 Processing Fee.
misdemeanor? (For the purpose of
this application, minor traffic vio-
lations should not be reported)
Part 4 - Superintendent’s Recommendation (Required if applicant is employed in WV School System)
Charges or convictions for driving
Applicants not employed in a WV school system must submit a Form 4B Character Recommendation.
while intoxicated (DWI) or driving
under the influence of alcohol or
I certify that I have reviewed and can attest to the accuracy and truthfulness of the information provided in this application. When necessary, I have
other
drugs
(DUI)
must
be
included documentation verifying this information. I have reviewed the disclosure of background information, and, to the best of my knowledge, the
reported. *
applicant is of good moral character and is physically, mentally, and emotionally qualified to perform the duties of a teacher. I recommend that s/he be
granted certification.
* For a YES response to items 5 & 6, the following must be
included: 1) Judgment Order –OR– 2) Final Order –OR–
3) Magistrate Court Documentation –AND– 4) all other relevant
_____________________________________________
_____________________________
________________________________
court documentation.
Signature of Superintendent
County
Date

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