Application for State Certification



APPLICATION FOR STATE CERTIFICATIONNEW JERSEY STATE DEPARTMENT OF EDUCATION CERTIFICATION (TEACHERS, SCHOOL LEADERS, EDUCATIONAL SERVICES PERSONNEL)RIDER UNIVERSITY STUDENT INFORMATIONBRONC ID #: FORMTEXT ????? PROGRAM: FORMDROPDOWN COMPLETION DATE (SEMESTER/YR): FORMDROPDOWN FORMDROPDOWN ADVISOR (LAST NAME): FORMTEXT ????? LAST NAME: FORMTEXT ?????FIRST NAME: FORMTEXT ????? MAIDEN NAME (if applicable): FORMTEXT ?????MIDDLE INITIAL: FORMTEXT ?Gender: FORMCHECKBOX MALE FORMCHECKBOX FEMALECELL PHONE #: FORMTEXT ?????HOME/ALT PHONE #: FORMTEXT ?????SOCIAL SECURITY #: FORMTEXT ?????DATE OF BIRTH: FORMTEXT ?????RACE (OPTIONAL): FORMDROPDOWN STREET ADDRESS: FORMTEXT ????? CITY: FORMTEXT ????? STATE: FORMTEXT ?? ZIP: FORMTEXT ?????EMAIL (non-Rider): FORMTEXT ?????ARE YOU A CITIZEN OF THE UNITED STATES? FORMCHECKBOX YES FORMCHECKBOX NO IF NO, HAVE YOU FILED A DECLARATION OF INTENTION? FORMCHECKBOX YES FORMCHECKBOX NO FORMCHECKBOX YES FORMCHECKBOX NO HAVE YOU EVER HAD A CERTIFICATE REVOKED OR SUSPENDED IN THIS OR ANY OTHER STATE? FORMCHECKBOX YES FORMCHECKBOX NO HAVE YOU EVER BEEN CONVICTED OF A CRIME IN THIS OR ANY OTHER STATE? CERTIFICATION(S) FOR WHICH YOU ARE APPLYING [You can only apply through Rider for certification programs enrolled in/completed through Rider.]TEACHERS FORMCHECKBOX Bilingual/Bicultural FORMCHECKBOX Business (Comprehensive) FORMCHECKBOX Early Childhood (P-3) FORMCHECKBOX Elementary (K-6) FORMCHECKBOX English FORMCHECKBOX ESL FORMCHECKBOX Marketing FORMCHECKBOX Mathematics FORMCHECKBOX Music FORMCHECKBOX Reading FORMCHECKBOX Social Studies FORMCHECKBOX Students with DisabilitiesForeign Languages: FORMCHECKBOX French FORMCHECKBOX German FORMCHECKBOX Spanish FORMCHECKBOX FORMTEXT ?????Elementary Education withMiddle School Subject Matter Specialization (5-8): FORMCHECKBOX Language Arts/Literacy FORMCHECKBOX Math FORMCHECKBOX Science FORMCHECKBOX Social StudiesSciences: FORMCHECKBOX Biology FORMCHECKBOX Chemistry FORMCHECKBOX Earth ScienceOTHER FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????SCHOOL LEADERS FORMCHECKBOX Principal FORMCHECKBOX School Administrator FORMCHECKBOX School Business Administrator FORMCHECKBOX Supervisor EDUCATIONAL SERVICES PERSONNEL FORMCHECKBOX Reading Specialist FORMCHECKBOX SAC FORMCHECKBOX School Counselor FORMCHECKBOX School PsychologistTEACHING EXPERIENCE (excludes substitute teaching and internships/practicum)DO YOU HAVE ANY TEACHING EXPERIENCE? FORMCHECKBOX YES FORMCHECKBOX NO DO YOU CURRENTLY HOLD A VALID TEACHER’S CERTIFICATE (CE, CEAS, Standard)? FORMCHECKBOX YES FORMCHECKBOX NO IF YES, LIST HIGHEST LEVEL OF EACH CURRENT CERTIFICATE HELD: FORMTEXT ?????DO YOU HOLD A VALID STANDARD CERTIFICATE IN ANOTHER STATE? FORMCHECKBOX YES FORMCHECKBOX NO IF YES, ATTACH A COPY OF EACH OUT OF STATE CERTIFICATE HELD.EDUCATIONAL OR WORK EXPERIENCE (LAST 2 POSITIONS). BEGIN WITH PRESENT. [NOTE: You may include substitute teaching (not student teaching). If you have never held a teaching position, complete for positions you have held even if it is not in the education field.]POSITION HELD: (optional for UGs) FORMTEXT ?????FROM (DATE): FORMTEXT ?????TO (DATE): FORMTEXT ?????EMPLOYER: (include County & District) FORMTEXT ?????BRIEF DESCRIPTION: FORMTEXT ?????POSITION HELD: (optional) FORMTEXT ?????FROM (DATE): FORMTEXT ?????TO (DATE): FORMTEXT ?????EMPLOYER: (include County & District) FORMTEXT ?????BRIEF DESCRIPTION: FORMTEXT ?????THIS SECTION IS FOR ADMINISTRATIVE USE ONLYDATE APPLICATION REC’DTOTAL STATE FEE(S) PAIDMETHOD OF PMT: [ ]CASH [ ]CHECK [ ]MONEY ORDER NUM: [ ]VI [ ]MC [ ]AMEX [ ]DISC NUM: *EXPIRATION: /TLAP PROFILE OTHER FEE(S) PAID (if appl.)METHOD OF PMT: [ ] CASH [ ] CHECK [ ]MONEY ORDER NUM: [ ]PRE-EXISTING [ ]NEW[ ]VI [ ]MC [ ]AMEX [ ]DISC NUM: *EXPIRATION: /COLLEGE RECORD (INCLUDE ALL COLLEGES, MOST CURRENT COLLEGE FIRST)COMPLETED PROFESSIONAL EDUCATION PROGRAM?(only list FINAL Cumulative GPA(s), where applicable)NAME OF COLLEGERIDER UNIVERSITYSTATENJDEGREE/CERTIFICATION FORMTEXT ?????YEAR FORMTEXT ???? FINAL GPA FORMTEXT ???? FORMCHECKBOX YES FORMCHECKBOX NO FORMTEXT ????? FORMTEXT ?? FORMTEXT ????? FORMTEXT ???? FORMTEXT ???? FORMCHECKBOX YES FORMCHECKBOX NO FORMTEXT ????? FORMTEXT ?? FORMTEXT ????? FORMTEXT ???? FORMTEXT ???? FORMCHECKBOX YES FORMCHECKBOX NOPRAXIS MULTI- SUBJECT AND/OR CONTENT KNOWLEDGE SCORES (WHERE APPLICABLE)LIST ALL RELEVANT PRAXIS TESTS AND SCORES. DO NOT INCLUDE PRAXIS CORE EXAMS FORMCHECKBOX CHECK if N/A (not applicable for the certification(s) you seek).(Please attach a copy of your ‘Test Taker Score Report’ reflecting test(s)/score(s), if not already provided to the Office of Field Placement and State Certification. [Note: The ‘‘Institution’ copy you may have had sent to Rider does not include all relevant information. The Test Taker/Examinee Score Report must include your SS# and it must indicate the NJ Department of Education (Code# R7666) as a Score Recipient for the NJ DOE to successfully match your score(s) to this application.]TEST DATETEST CODETEST NAME [For multi-subj. sub-test scores (ie ElemEd), list each test/score on a single line and check only if passed all 4 parts.]HIGHEST SCOREPASSEDWAS THIS ATEST RETAKE FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMCHECKBOX YES FORMCHECKBOX NO FORMCHECKBOX YES FORMCHECKBOX NO FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMCHECKBOX YES FORMCHECKBOX NO FORMCHECKBOX YES FORMCHECKBOX NO FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMCHECKBOX YES FORMCHECKBOX NO FORMCHECKBOX YES FORMCHECKBOX NO FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMCHECKBOX YES FORMCHECKBOX NO FORMCHECKBOX YES FORMCHECKBOX NO FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMCHECKBOX YES FORMCHECKBOX NO FORMCHECKBOX YES FORMCHECKBOX NOWPT & OPI TESTS (FOR LANGUAGE CERTIFICATIONS ONLY, WHERE APPLICABLE)LIST ALL RELEVANT LTI OPI/WPT TESTS. FORMCHECKBOX CHECK if N/A (not applicable for the certification(s) you seek).WPT and/or OPILANGUAGE (if more than four tests, you can list WPT/OPI tests together, by language)HIGHEST SCOREPASSED FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN FORMCHECKBOX YES FORMCHECKBOX NO FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN FORMCHECKBOX YES FORMCHECKBOX NO FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN FORMCHECKBOX YES FORMCHECKBOX NO FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN FORMCHECKBOX YES FORMCHECKBOX NOIncomplete applications will not be PLETE AND SIGN THE SECTIONS BELOW IN THE PRESENCE OF A NOTARY PUBLIC.You will need a valid, state-issued, picture ID (ie driver’s license).APPLICANT ACKNOWLEDGEMENTS[______] I understand that it is my responsibility to ensure the state has received my Praxis scores in order for my certification(s) to be issued.[______] I give permission to Field Placement/State Certification to request official Rider University transcripts for state certification purposes.[______] I understand that Rider University cannot endorse my certification(s) with the state until my transcript is conferred, accordingly.[______] I understand that I must apply directly with the state for additional certifications (for programs not enrolled in/completed through Rider).[______] I understand that I must complete a state-generated survey (emailed to me by the state) before the state will ‘issue’ my certification(s). [______] I understand that it can take up to nine weeks (after the close of the semester) for my certification(s) to be ‘issued’ by the state (TLAP).[______] GRs ONLY: I understand that I must provide Field Placement/State Certification an unofficial copy of my conferred, undergrad transcript(s).[______] GRs ONLY: I understand that I must complete a Graduation Clearance Form for Terri Podgorski in order to be cleared for certification.PLEASE NOTE: The Oath of Allegiance below is only valid for a six-month time period. Should you have a program completion delay, you will need to make another certification appointment to complete a new application and Oath.New Jersey State Department of Education Office of Certification and Induction OATH OF ALLEGIANCE / VERIFICATION OF ACCURACYUNITED STATES CITIZEN OATH OF ALLEGIANCE*-382270113030NOTARY MUST BE PRESENT FOR THESE SECTIONS00NOTARY MUST BE PRESENT FOR THESE SECTIONSI, __________________________________ do solemnly swear, (or affirm) that, I will support the Constitution of the United Statesand the Constitution of the State of New Jersey and that I will bear true faith and allegiance to the same and to the governments established in the United States and in this State, under the authority of the people, so help me God.Certification Failure to complete these items will result in rejection of the candidate’s application for certification. 1.Have you ever been convicted of, pled guilty, no contest or nolo contendere to, or had adjudication withheld to a crime or offense, including DUI, in New Jersey or any other state or jurisdiction? If yes, complete and submit a Criminal/Offense Information Form. FORMCHECKBOX YES FORMCHECKBOX NO 2. Have you ever had an education or other professional certificate, license or credential revoked, suspended, invalidated or denied for cause in New Jersey or any other state or jurisdiction?* FORMCHECKBOX YES FORMCHECKBOX NO3. Have you ever surrendered or relinquished an education or other professional certificate, license or credential in New Jersey or any other state or jurisdiction? * FORMCHECKBOX YES FORMCHECKBOX NO 4. Are you the subject of any pending action or proceedings against your education or other professional certificate(s), license(s) or credential(s) in New Jersey or any other state or jurisdiction? * FORMCHECKBOX YES FORMCHECKBOX NO 5. Have you ever resigned, retired or been dismissed or suspended from an education-related position in New Jersey or any other state or jurisdiction following allegations of misconduct? * FORMCHECKBOX YES FORMCHECKBOX NO 6. Are you the subject of any civil, criminal or administrative investigation in New Jersey or any other state or jurisdiction? * FORMCHECKBOX YES FORMCHECKBOX NO * If any answer to Questions 2 through 6 is “yes,” complete and submit an Additional Information For the Oath of Allegiance Form.PROOF OF ID (legal, picture ID):State FORMTEXT ?? Expiration Date FORMTEXT ?????DL# FORMTEXT ?????VERIFICATION OF ACCURACY: I certify that all statements and information provided herein are true and accurate.______________________________________________________APPLICANT SIGNATURE DateNOTARY SEALSWORN AND SUBSCRIBED TO BEFORE ME this day:______________________________________________________NOTARY SIGNATURE DateNON-CITIZENYOU MUST COMPLETE A NON-CITIZEN OATH OF ALLEGIANCE AND AN AFFIDAVIT OF INTENT TO BECOME A CITIZEN. ENCLOSED FORMCHECKBOX YES FORMCHECKBOX NO ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download