Florida Department of Education Bureau of Educator ...
Florida Department of Education Bureau of Educator Certification Room 201, Turlington Building 325 West Gaines Street Tallahassee, FL 32399-0400
Applicant's Personal Information Social Security Number
DOE Number
Date of Birth (MM/DD/YYYY)
First Name Last Name
Communication Number
CT 111
REQUEST FOR ISSUANCE OF AN INITIAL FLORIDA EDUCATOR'S CERTIFICATE FOR USE BY STATE SUPPORTED AND NONPUBLIC SCHOOLS
Note: Only schools which have a system for demonstration of Professional Education Competence (PEC) that has been approved by the Florida Department of Education may request a certificate.
Choose one of the following:
Initial Florida Educator's Certificate
Athletic Coaching Certificate
Complete the Applicant Information below: Begin Date of Certificate Validity: July 1,
Date Employed:
Street Address:
City:
Email:
@
Complete the School/Organization Information below: Name of School:
Name of PEC Organization:
Zip Code:
City:
Zip Code:
Telephone:
Email:
@
Applicant completed fingerprint submission on
via an FDLE-approved Livescan Service Provider.
MM/DD/YY
Background screening results will be sent directly to DOE/Teacher/Certification [ORI = FL921620Z].
Select the correct citizenship status:
1.
Applicant is a citizen of the United States.
2.
Applicant is not a citizen of the United States, but is eligible for employment. A photocopy of the I-9 form
verifying eligibility for employment signed by an official of this school/organization is attached.
I certify the above information is true and accurate.
Print Name:
Signature:
(Chief Administrative Officer or Authorized Designee)
Date:
December 2013
................
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