Get Form 4020e Wa

NAME PRINTED AND TITLE Program Director of Organization/Chairperson/Dean of Education Department/ Certification Office FORM SPI/CERT 4020E Rev. 2/12 SIGNATURE RETURN COMPLETED FORM TO THE APPLICANT. OFFICE 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 http / /www. k12. wa*us/certification/ E-Mail cert k12. wa*us UCTIO STR N IN RINTEN PE DE SU OF PUBLI C T W AS HIN GTO VERIFICATION OF PROGRAM COMPLETION AND CHARACTER ALL SECTIONS must be completed* Send it to the institution/organization where you completed your teacher preparation and certification program* This form when returned to you is to be included with your application packet. If you were trained outside the U*S* and Canada use Form SPI 4030 instead of this form* 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 BUSINESS 6. E-MAIL HOME The above named is an applicant for teacher certification in Washington State. To be valid this form must be signed by the program director of the organization or the dean of the college or school of education the certification officer the chair of the education department or the dean s designee at the institution where the applicant completed his/her teacher preparation and certification program* A stamped signature must be initialed by the person using the stamp* RETURN THIS FORM TO THE APPLICANT. A. Has this applicant completed your state-approved teacher education program Date of program completion* Date of student teaching. YES NO If no what were the deficiencies B. Was he/she eligible for certification in your state at the completion of the teacher preparation program C. Did the applicant complete his/her practicum/student teaching in a Washington school For D E please note In order to qualify for an endorsement area the applicant must have completed an approved program in that area* Each endorsement program must include coursework in methodology for that content area and completion of a supervised classroom-based field experience/internship that includes instruction in that content area* D. Area in which applicant is recommended for certification* Please indicate area and grade level s. AREA GRADE LEVEL S E* Other approved content area/endorsement programs that applicant has completed F* Do you have knowledge that the applicant has been arrested charged or convicted of any crime or has a history of any serious behavioral problems List any reason you know of why this applicant should not be certified in Washington* NAME OF INSTITUTION/ORGANIZATION DATE By signing this form I attest that the above information is true and accurate to the best of my knowledge. OFFICE 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 http / /www. k12. wa*us/certification/ E-Mail cert k12. wa*us UCTIO STR N IN RINTEN PE DE SU OF PUBLI C T W AS HIN GTO VERIFICATION OF PROGRAM COMPLETION AND CHARACTER ALL SECTIONS must be completed* Send it to the institution/organization where you completed your teacher preparation and certification program* This form when returned to you is to be included with your application packet.