Application For Washington State Conditional Certificate Page 6
Download a blank fillable Application For Washington State Conditional Certificate in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Application For Washington State Conditional Certificate with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12OFFICE OF SUPERINTENDENT OF PUBLIC INSTRUCTION
Professional Certification
Office of Professional Practices
Old Capitol Building, PO BOX 47200
OLYMPIA WA 98504-7200
OPP (360) 725-6130 TTY (360) 664-3631
Web Site: http:/ /
E-Mail: cert@k12.wa.us
CHARACTER AND FITNESS SUPPLEMENT
Please complete the following questions carefully and completely before providing information and signing the affidavit. Any
falsification or deliberate misrepresentation, including omission of a material fact, in completion of this application can be
grounds for denial of certification, or in the case of a certificate holder, reprimand, suspension, or revocation of the
educational certificate, credential, or license.
ALL REQUIRED DOCUMENTATION REQUESTED BELOW MUST ACCOMPANY THIS FORM. ALL QUESTIONS MUST BE
ANSWERED. IF ADDITIONAL SPACE IS NEEDED, ATTACH ON A SEPARATE SHEET OF PAPER.
SECTION I - PERSONAL INFORMATION (please print or type)
2. MAIDEN NAME
1. NAME
LAST
FIRST
MIDDLE
3. ADDRESS
4. DATE OF BIRTH
5. SOCIAL SECURITY NO. (OPTIONAL)
CITY/STATE/ZIP
6. TELEPHONE
7.
E-MAIL
(
)
(
)
BUSINESS:
HOME:
8. Please list all former names you have used and approximate dates of use. (If more than three, list on separate sheet of paper.)
Date
Date
Date
SECTION II - PROFESSIONAL FITNESS
Yes
No
1.
Have you ever held or do you currently hold a Washington education certificate?
2.
Have you ever held or do you currently hold any education certificate, credential or license authorizing service in
the public/private schools in another state, province, territory, or country? If “yes,” list the states, provinces,
territories, and/or countries:
3.
Are you currently or have you ever been the subject of any certificate or licensing investigation or inquiry by any
certification or licensing agency for allegations of misconduct? If “yes,” on a separate sheet of paper, list the
agency, including complete address and telephone number as well as the purpose of the investigation or inquiry.
If you answer “yes” to questions 4 through 11 (Section II), on a separate sheet of paper, give a complete explanation,
including duties, circumstances, and supporting documentation.
4.
Have you ever had any adverse action taken on any certificate or license? (Adverse action includes letters of
warning, reprimands, suspensions [including stayed], revocations, voluntary surrenders, or voidance.)
5.
Have you ever been denied, or otherwise rejected for cause, an education certificate, credential, or license?
6.
Have you ever withdrawn an application for any education certificate, credential, or license?
7.
Have you ever practiced in any educational position in a public school for which you did not hold the appropriate
valid educational certificate, credential, or license for that position?
8.
Have you ever been dismissed, discharged, or fired from any employment position involving children or
dependent adults? (Do not include RIFs)
9.
Have you ever resigned from or otherwise left any employment (e.g., settlement agreement) while allegations of
misconduct were pending?
FORM SPI/CERT 4020B (Rev. 9/15)
Page 1 of 4
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business