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Get PA PDE-5005 2013-2024

Name Social Security Number Home Mailing Address City Name of Private Academic School State Birthdate Zip Code Sex Home Phone Number School Location Address Phone Number Email Address EDUCATION Name of College s Attended Dates Attended Degree/Credits Major CERTIFICATION Private Academic School Instructional I or II Educational Specialist Supervisory Administrative Type of Certificate Subjects Listed on Certificate Issuing Authority Date Issued Grade Level Subjects Taught Title or Position PROFESSIONAL EXPERIENCE Date of Experience PDE-5005 2/13 Name of School Location Describe job duties expected to be performed Submit the following 35. EDUCATION DIRECTOR APPLICATION FOR DEPARTMENT OF EDUCATION USE ONLY Check Date Check No* P Kind of Check S MO Type of School License AUN INSTRUCTIONS Submit application and required fee and documentation to Department of Education Division of Planning Private Academic Schools Section 333 Market St 3rd Fl Harrisburg PA 17126. 00 check or money order made payable to the Commonwealth of Pennsylvania Copy of PA teaching certificate Copy of FBI state police and child abuse clearances and PDE 6004 Arrest/Conviction Form Three letters of professional reference Section 51. 36 HEALTH CERTIFICATE I certify that I am a physician legally qualified to practice medicine in the Commonwealth of Pennsylvania that I have examined the above named person and find said person neither mentally nor physically disqualified by reason of tuberculosis or any other chronic or acute defect from successfully performing the duties of a teacher. Address-Street City State and Zip Code Physician s License Number Signature of Examining Physician APPLICANT S STATEMENT I certify that the information and record presented on this form are true and accurate to the best of my knowledge and belief* Signature of Applicant Date. 00 check or money order made payable to the Commonwealth of Pennsylvania Copy of PA teaching certificate Copy of FBI state police and child abuse clearances and PDE 6004 Arrest/Conviction Form Three letters of professional reference Section 51. 36 HEALTH CERTIFICATE I certify that I am a physician legally qualified to practice medicine in the Commonwealth of Pennsylvania that I have examined the above named person and find said person neither mentally nor physically disqualified by reason of tuberculosis or any other chronic or acute defect from successfully performing the duties of a teacher. 36 HEALTH CERTIFICATE I certify that I am a physician legally qualified to practice medicine in the Commonwealth of Pennsylvania that I have examined the above named person and find said person neither mentally nor physically disqualified by reason of tuberculosis or any other chronic or acute defect from successfully performing the duties of a teacher. Address-Street City State and Zip Code Physician s License Number Signature of Examining Physician APPLICANT S STATEMENT I certify that the information and record presented on this form are true and accurate to the best of my knowledge and belief* Signature of Applicant Date. .

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