Application For Washington State Conditional Certificate Page 5
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1210.
List the name of every community college, undergraduate, and graduate institution you have attended in the space below and
provide the additional information requested.
Dates Attended
Location
Degrees
Post BA Credits Earned
From
Institution
To
City/State
Granted
Semester
Quarter
Attach separate page for additional education, if necessary.
11.
Official transcripts (those with the college or university seal) must be submitted and attached to this page of your application.
List all transcripts that you are providing:
NOTE:
ALL OFFICIAL TRANSCRIPTS NEEDED TO EVALUATE YOUR APPLICATION FOR A CERTIFICATE MUST BE
SUBMITTED WITH THIS APPLICATION.
AFFIDAVIT
I, _________________________________, certify (or declare) under penalty of perjury under the laws of the state of
Washington that the foregoing and all information included in this application is true and correct. If the answers to any
question on the application or the character and fitness supplement change prior to my being granted certification, I must
immediately notify Professional Certification at OSPI.
Signature
Date
City
State
THIS FORM MUST BE INCLUDED IN THE APPLICATION PACKET. ATTACH YOUR CHECK TO THIS FORM.
Page 2
FORM SPI/CERT 4025A (Rev. 9/15)
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