Free Wv 39 Template

Office of Professional Preparation

Applicant Information Page for Permits/Authorizations that Require Employment

Check if applicable:

 Self or spouse on Active Duty

Building 6, Room 722

Date Received by County Board of Education:

____________________________

 Self or spouse within 6 months after

1900 Kanawha Boulevard East

Charleston, WV 25305

Active Duty

304-558-7010 7/01/14

Date Received by Institution of Higher Education: ___

_________________

See our website for additional documents required.

Part 1 -Applicant Information

Part 2-Disclosure of Background Information

_________________

__________________

_____________

_________________

_____________________

If you answer yes to any question

Documentation Attached

below, SUBMIT a narrative with

Social Security Number

Birth Date (MM-DD-YYYY)

Gender (M or F)

US Citizen ( Y or N)

US Veteran or Spouse of veteran

your

application.

The narrative

YES

( Y or N) If Yes complete box -top right

should include dates, locations, school

NO

____________________________________

______________________________ _____ ________________________________________

systems, and all/any other information

Last Name

First Name

MI

Previous Last Name (Maiden)

that

explains the

circumstance(s) in

(If your name has changed since your last application, proof of name change must be attached e.g. photocopy of marriage certificate, etc.)

detail.

_______________________________________________________ _____________________________________ _______ ______________

1) Have you ever had adverse action

taken

against

any

application,

Street Address

City

State

Zip Code

certificate, or license in any state?

__________________________________ ___________________________________ ____________________________________________

Adverse

action

includes

but is

not

limited

to

the

following: letter of

Primary Phone

Secondary Phone

E-Mail

warning, reprimand, denial, suspen-

List the institutions from which a degree has been earned

Are you currently employed by

Do you currently hold a License to

sion,

revocation,

voluntary surrender

a West Virginia School System?

work in the public schools of West

or cancellation.

Yes

No

Virginia?

Yes

No

College/University

Degree

Date

2) Have you ever been disciplined,

If YES, please indicate the

Do you currently hold a License to

reprimanded,

suspended,

or

school system:

work in the public schools of an-

discharged

from

any

employment

other state?

because of allegations of misconduct?

Yes

No

3) Have you ever resigned, entered

Part 3—Applicant Signature

into a settlement agreement, or oth-

erwise left employment as a result of

alleged misconduct?

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

4) Is any action now pending against

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)

that I am seeking or currently hold.

you for alleged misconduct in any

school district, court, or before any

___________________________________________

__

_________________________

educator licensing agency?

Signature of Applicant

Date

5) Have you ever been arrested,

A non-refundable fee is required for each application. You may pay

Supporting documentation attached:

charged

with,

convicted

of, or

are

online at https://wveis.k12.wv.us/certpayment/.

Applications attached:

(non-fee required Forms, e.g. Forms 4B, 7, V10, V16)

currently under indictment for a felo-

______________ ______________

______________

______________

______________ ______________

ny? *

Form #

Form #

Form #

Form #

Form #

Form #

6) Have you ever been arrested,

charged with or convicted of a

mis-

Part 4—Fingerprinting Information

demeanor? (For the purpose of this

application,

minor traffic violations

First-time applicants are required to have fingerprints processed by L-1 Solutions (L1enrollment.com).

should not be reported) Charges or

□ I have previously received Certification in WV and understand that I do not need to re-submit my fingerprints.

convictions for driving while intoxicat-

ed (DWI) or driving under the influ-

□ I have never held WV Certification and have recently submitted my fingerprints to L1 Solutions on ______/______/_________

ence of alcohol or other drugs (DUI)

(L1 Transaction #________________________)

must be reported. *

Part 5 - Superintendent Recommendation (Required for Permit/Authorization Application)

* For a YES response to items 5 & 6, the follow-

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

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)

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-

granted certification.

istrate Court Documentation; AND 4) all other

____________________________________

_________

_____________________________

________________________________

relevant court documentation.

Signature of Superintendent

County

Date