Application For Washington State Conditional Certificate Page 9
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12ALL APPLICANTS MUST COMPLETE THE AFFIDAVIT
AFFIDAVIT
I, ___________________________________ certify (or declare) under the penalty of perjury under the laws of the state of
Washington that the foregoing and all information included in the application is true and correct.
If the information provided or answer(s) to any question on the application or character and fitness supplement changes prior to my
being granted certification, I must immediately notify the Office of Professional Practices and my college/university if I am a
college/university candidate.
I understand I must answer this application truthfully and completely. 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.
SIGNATURE
DATE
CITY/STATE
COLLEGE/UNIVERSITY STUDENTS ONLY
Please also complete the release below:
AFFIDAVIT
I hereby authorize ___________________________________________ to release, orally or in writing as may be requested,
(name of college/university)
all student records and other personally identifiable information to the Office of the Superintendent of Public Instruction
(OSPI) for the purpose of investigating and determining my eligibility for Washington State certification pursuant to
RCW 28A.410, WAC 181-86, and WAC 181-87, as now or hereafter amended
.
SIGNATURE OF APPLICANT
DATE
FORM SPI/CERT 4020B (Rev. 9/15)
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