Application For Washington State Conditional Certificate Page 12
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12OFFICE OF SUPERINTENDENT OF PUBLIC INSTRUCTION
Professional Certification
OLD CAPITOL BUILDING, PO BOX 47200
OLYMPIA WA 98504-7200
(360) 725-6400 TTY (360) 664-3631
Web Site:
E-Mail: cert@k12.wa.us
VERIFICATION OF MASTER'S DEGREE PROGRAM ENROLLMENT
Only use this form if you are applying for a second conditional school speech-language pathologist or audiologist
certificate.
Complete Section A of this form. Send it to the education department or appropriate department of the college/university
where you are completing your master's degree program. This form, when returned to you, is to be included with your
application packet.
First conditional certificates, issued to speech-language pathologists or audiologists after June 30, 2003, which are valid
for up to two years, may be reissued once for up to two years, if the individual provides evidence that he/she is enrolled
in and completing satisfactory progress in a master's degree program resulting in the initial ESA school
speech-language pathologist or audiologist certificate.
SECTION A
TO BE COMPLETED BY APPLICANT
1.
NAME
LAST
FIRST
MIDDLE
MAIDEN/FORMER NAME
2.
ADDRESS
3.
DATE OF BIRTH
CITY/STATE/ZIP
4.
SOCIAL SECURITY NO. (OPTIONAL)
5.
TELEPHONE:
6.
E-MAIL
(
)
(
)
BUSINESS
HOME
7.
CERTIFICATE NUMBER
SECTION B
TO BE COMPLETED BY COLLEGE/UNIVERSITY
The above-named is an applicant for a conditional ESA certificate in Washington State. Complete information in Section B
regarding this applicant. To be valid, this form must be signed by the dean or certification officer of the college or the chair of
the department at the institution where the applicant is currently completing his/her master's degree program. A stamped
signature must be initialed by the person using the stamp. Verify the information with the school seal. RETURN THIS FORM
TO THE APPLICANT.
A.
Is the applicant currently enrolled in a master's degree program for Speech Language Pathology or Audiology?
Yes
No
B.
Is the applicant completing satisfactory progress in the program?
Yes
No
C.
Anticipated date of program completion.
Do you have knowledge that the applicant has been
D.
List any reason you know of why this applicant should not be
YES
arrested, charged, or convicted of any crime or has a
certified in Washington.
NO
history of any serious behavioral problems?
NAME OF COLLEGE/UNIVERSITY
DATE
ADDRESS
COLLEGE SEAL
E-MAIL
CITY/STATE/ZIP
This form must bear the
college/university seal.
TELEPHONE
NAME (PRINTED)
(
)
SIGNATURE AND TITLE (Chairperson of Education Department/Certification Officer)
FORM SPI/CERT 4025E-1 (Rev. 9/15)
RETURN COMPLETED FORM TO THE APPLICANT
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