EXPEDITED SERVICE REQUEST FORM - Office of Higher ...



EXPEDITED SERVICE REQUEST FORM

| |(Last) |(First) |

|Applicant’s | | |

|Name |     |      |

| |Is the Online Application Ready for |Has your BOCES submitted documentation to the Office of Teaching? |

|SSN: |Review? |Yes, date:       |

|(last four digits) |Yes No |Blue/Green/Pink Sheet (Underline One) |

| | |No |

|      |Has Applicant Applied to Your BOCES? | |

| |Yes No | |

|Has your BOCES completed the |If yes, verify the following: |If no, verify the following: |

|evaluation? | | |

|Yes, date      |Passed all required exams |Passed all required exams |

|No |Required workshops completed |Required workshops credited |

| |All academic requirements met | |

|Certificate Title Requested: | |

| |      |

|Title of Position Offered |      |

|Employing School District | |

| |      |

|Name of School District | |

|Superintendent |      |

| | |

|School District Address |      |

|Superintendent’s | |Sup’ts | |

|E-Mail Address |      |Telephone |      |

| | |Number | |

|Name of Regional Certification|Print/Type Name: | |RCO’s Email Address: |

|Officer (RCO) |      | |      |

|Submitting Request | | | |

| |RCO’s address: | |Date: |

| |      | |      |

|Office of Teaching Initiatives Use Only: |

| |If no, check reason for not issuing: |

|Date Received:       |Exams |

| |Workshops |

|Date Completed:       |Coursework |

| |Fingerprints |

|Was Certificate Issued: Yes No |Notes:       |

| | |

|Last Name of Evaluator:       | |

Complete and email this form to tcregcert@mail.. If you are forwarding documentation received by your BOCES, attach a copy of this form to your submission and mail to the NYS Education Department, Office of Teaching Initiatives, Room 5N, 89 Washington Avenue, Albany, NY 12234 – Attention: Box ES.

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