Special Temporary Certificate in Educational Leadership
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
First Name
DOE Number
Last Name
Date of Birth (MM/DD/YYYY)
Communication Number
CT 110S
REQUEST FOR ISSUANCE OF A SPECIAL TEMPORARY FLORIDA EDUCATOR'S CERTIFICATE COVERING EDUCATIONAL LEADERSHIP
Note: Only public schools and nonpublic 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.
Complete the Applicant Information below:
Begin Date of Certificate Validity: July 1,
Date Employed:
Street Address:
City
Zip Code
Email:
@
Complete the EmploymentExperience Verification Informationbelow:
Executive Management or Leadership Position:
Employer:
Employment Begin Date:
Employment End Date:
The employment verified herein is approved as three (3) years of full-time, successful experience acceptable to meet eligibility requirements for the special temporary certificate in Educational Leadership.
Applicant completed fingerprint submission on
via an FDLE-approved Livescan Service Provider.
MM/DD/YYYY
Background screening results have been 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.
Complete the Organization Information below:
Name of District orPEC Organization:
City Telephone:
Email:
Zip Code @
A Florida state-certified school administrator shall be designated to serve as the educational leadership mentor for this Applicant during the term of the special temporary certificate in Educational Leadership. As a duly authorized officer of my school district/organization, I certify that all the above information is true and accurate.
Signature:
Date:
(Superintendent, Chief Administrative Officer or Authorized Designee)
March 2014
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