Point Park University
School of EducationVerification of Registration for American Board CertificationPLEASE TYPE and SignName:_____________________________________________________________DOB: _____________ Area of Certification: ___________________________________________________________________Home Address: ________________________________________________________________________City: ____________________________________ State:_______Zip Code: __________________Cell Phone: ______________________________________Email: _______________________________When do you plan to do your 12 week ABCTE Teaching/Mentorship? _____________________________PA County for 12 week ABCTE Teaching/Mentorship: _________________________________________I am currently enrolled in the American Board Program.Candidates Signature: ____________________________________________________________Date: ____________________________________ ................
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