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Get NY OSPRA 104 2007

OSPRA 104 10/07 Authorization to Forward Criminal History Record Information from the City School District of the City of New York to the New York State Education Department Office of School Personnel Review and Accountability NYS Education Department ph 518 473-2998 www. Highered.nysed.gov/tcert/ospra OSPRA mail.nysed.gov Type or Print All Information Instructions to Applicant Please complete Sections 1 2 and 3 and mail the form to the address in Section 4. Please Note This form is to be filed by individuals who have been previously fingerprinted after July 1 1990 for a license and/or employment by the New York City Board of Education NYCBOE and are authorizing the NYCBOE to forward their criminal history to the New York State Education Department for certification application and/or employment purposes. SECTION 1 Inaccurate or incomplete information will delay processing Name Last First Middle Sex M/F Home Address Street Apt. Social Security Number City State Zip Telephone Area Code and Number E-mail Address Date of Birth Month Day Year Please choose one of the following I am leaving or have left the employ of the NYCBOE and am seeking clearance for certification and/or employment. I am remaining in the employ of the NYCBOE and I am seeking clearance for certification* the NYCBOE* I hereby authorize the NYCBOE to forward the content of my criminal history record as secured from DCJS and the FBI to the New York State Education Department as a condition of my application for certification and/or clearance for employment. I further understand that the NYCBOE is authorized to forward subsequent criminal history notifications received from DCJS to the New York State Education Department. I understand that if my fingerprints have not been retained by DCJS I will have to be fingerprinted again to meet the requirements of Chapter 180 of the Laws of 2000. prospective employer before a clearance will be issued* Signature Date Division of Human Resources MAIL TO HR Connect Walk-in Center 65 Court Street Room 102 Brooklyn New York 11201 Ph 718 935-4000 Fax 718 935-2726. Please Note This form is to be filed by individuals who have been previously fingerprinted after July 1 1990 for a license and/or employment by the New York City Board of Education NYCBOE and are authorizing the NYCBOE to forward their criminal history to the New York State Education Department for certification application and/or employment purposes. SECTION 1 Inaccurate or incomplete information will delay processing Name Last First Middle Sex M/F Home Address Street Apt. SECTION 1 Inaccurate or incomplete information will delay processing Name Last First Middle Sex M/F Home Address Street Apt. Social Security Number City State Zip Telephone Area Code and Number E-mail Address Date of Birth Month Day Year Please choose one of the following I am leaving or have left the employ of the NYCBOE and am seeking clearance for certification and/or employment. Social Security Number City State Zip Telephone Area Code and Number E-mail Address Date of Birth Month Day Year Please choose one of the following I am leaving or have left the employ of the NYCBOE and am seeking clearance for certification and/or employment. I am remaining in the employ of the NYCBOE and I am seeking clearance for certification* the NYCBOE* I hereby authorize the NYCBOE to forward the content of my criminal history record as secured from DCJS and the FBI to the New York State Education Department as a condition of my application for certification and/or clearance for employment. .

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