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Office of Professional Preparation |
Applicant Information Page for Permits/Authorizations that Require Employment |
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Check if applicable: |
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Self or spouse on Active Duty |
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Building 6, Room 722 |
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Date Received by County Board of Education: |
____________________________ |
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Self or spouse within 6 months after |
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1900 Kanawha Boulevard East |
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Charleston, WV 25305 |
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Active Duty |
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304-558-7010 7/01/14 |
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Date Received by Institution of Higher Education: ___ |
_________________ |
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See our website for additional documents required. |
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Part 1 -Applicant Information |
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Part 2-Disclosure of Background Information |
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_________________ |
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__________________ |
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_________________ |
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_____________________ |
If you answer yes to any question |
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Documentation Attached |
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below, SUBMIT a narrative with |
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Social Security Number |
Birth Date (MM-DD-YYYY) |
Gender (M or F) |
US Citizen ( Y or N) |
US Veteran or Spouse of veteran |
your |
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application. |
The narrative |
YES |
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( Y or N) If Yes complete box -top right |
should include dates, locations, school |
NO |
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______________________________ _____ ________________________________________ |
systems, and all/any other information |
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Last Name |
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First Name |
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MI |
Previous Last Name (Maiden) |
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that |
explains the |
circumstance(s) in |
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(If your name has changed since your last application, proof of name change must be attached e.g. photocopy of marriage certificate, etc.) |
detail. |
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_______________________________________________________ _____________________________________ _______ ______________ |
1) Have you ever had adverse action |
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taken |
against |
any |
application, |
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Street Address |
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City |
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State |
Zip Code |
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certificate, or license in any state? |
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__________________________________ ___________________________________ ____________________________________________ |
Adverse |
action |
includes |
but is |
not |
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limited |
to |
the |
following: letter of |
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Primary Phone |
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Secondary Phone |
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E-Mail |
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warning, reprimand, denial, suspen- |
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List the institutions from which a degree has been earned |
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Are you currently employed by |
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Do you currently hold a License to |
sion, |
revocation, |
voluntary surrender |
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a West Virginia School System? |
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work in the public schools of West |
or cancellation. |
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Yes |
No |
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Virginia? |
Yes |
No |
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College/University |
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Degree |
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Date |
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2) Have you ever been disciplined, |
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If YES, please indicate the |
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Do you currently hold a License to |
reprimanded, |
suspended, |
or |
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school system: |
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work in the public schools of an- |
discharged |
from |
any |
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employment |
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other state? |
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because of allegations of misconduct? |
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Yes |
No |
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3) Have you ever resigned, entered |
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Part 3—Applicant Signature |
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into a settlement agreement, or oth- |
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erwise left employment as a result of |
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alleged misconduct? |
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I swear or affirm under the penalty of false swearing that all information provided in or with this application is true, correct, and complete to the best of my knowledge. I |
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4) Is any action now pending against |
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understand that any false statements, misrepresentations, or omissions of fact in or with this application are grounds for denial, suspension, or revocation of the license(s) |
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that I am seeking or currently hold. |
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you for alleged misconduct in any |
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school district, court, or before any |
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___________________________________________ |
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_________________________ |
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educator licensing agency? |
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Signature of Applicant |
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Date |
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5) Have you ever been arrested, |
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A non-refundable fee is required for each application. You may pay |
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Supporting documentation attached: |
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charged |
with, |
convicted |
of, or |
are |
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online at https://wveis.k12.wv.us/certpayment/. |
Applications attached: |
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(non-fee required Forms, e.g. Forms 4B, 7, V10, V16) |
currently under indictment for a felo- |
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______________ ______________ |
______________ |
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______________ |
______________ ______________ |
ny? * |
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Form # |
Form # |
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Form # |
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Form # |
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Form # |
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Form # |
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6) Have you ever been arrested, |
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charged with or convicted of a |
mis- |
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Part 4—Fingerprinting Information |
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demeanor? (For the purpose of this |
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application, |
minor traffic violations |
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First-time applicants are required to have fingerprints processed by L-1 Solutions (L1enrollment.com). |
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should not be reported) Charges or |
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□ I have previously received Certification in WV and understand that I do not need to re-submit my fingerprints. |
convictions for driving while intoxicat- |
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ed (DWI) or driving under the influ- |
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□ I have never held WV Certification and have recently submitted my fingerprints to L1 Solutions on ______/______/_________ |
ence of alcohol or other drugs (DUI) |
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(L1 Transaction #________________________) |
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must be reported. * |
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Part 5 - Superintendent Recommendation (Required for Permit/Authorization Application) |
* For a YES response to items 5 & 6, the follow- |
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I certify that I have reviewed and can attest to the accuracy and truthfulness of the information provided in this application. |
When necessary, I have |
ing must be included for all charges, including |
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included documentation verifying this information. I have reviewed the disclosure of background information, and, to the best of my knowledge, the |
those that have been dismissed or expunged: 1) |
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applicant is of good moral character and is physically, mentally, and emotionally qualified to perform the duties of a teacher. I recommend that s/he be |
Judgment Order; OR 2) Final Order; OR 3) Mag- |
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granted certification. |
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istrate Court Documentation; AND 4) all other |
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____________________________________ |
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_________ |
_____________________________ |
________________________________ |
relevant court documentation. |
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Signature of Superintendent |
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County |
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Date |
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