Fillable CERTIFICATION AND EXAM VERIFICATION APPLICATION (Teach Louisiana)

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CERTIFICATION AND EXAM VERIFICATION APPLICATION (Teach Louisiana)

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P
age 1 (Revised August 1, 2021)
Application Type - VR
CERTIFICATION AND EXAM VERIFICATION APPLICATION
By completing this application, educators may reques
t official Louisiana certification and/or exam verification. Verification
will be provided via the online portal in response to the certification submission case and can be sent to other agencies if
noted in the reques
t. A $25 handling/processing fee is required for this type of request. Certification may be officially verified
online for no charge at www.teachlouisiana.net. Louisiana’s certification structure and policies are outlined in Bulletin 746,
Louisiana Standards for State Certification of School Personnel. All questions regarding certification requirements or the
process, can be answered by contacting the certification staff through the online educator certification portal at
ldoe.force.com.
Submitting the Application
Submit a completed application packet (including required documentation) through the online educator certification portal
.
The following items are required* as part of a complete application packet and must be signed and dated with current date:
1. Copy of Applicant Social Security Card and Driver’s License* (these are required with every application even if
name change is not requested)
2. This Application form*
3. Professional Conduct form with all questions answered, signed, and dated by the applicant*
4. Supplemental Documents– forms or documents which need to be completed for verification by the Louisiana
Department of Education (e.g. other state’s documents used to verify certification or Praxis exams) or clear, writt
en
explanation of verification needed and how to provide it
5. Copy of Online Payment Confirmation email or screenshot* - Applicant will access the payment portal thro
ugh
t
he educator account on TeachLA Live! portal
so that the fee, appropriate to the request, can be made to LDOE.
Handwritten documents will not be accepted for certification processing.
Indicate request:
Copy or Verification of Exams
Verification of Certification (Enclose additional instructions, explaining your request if
a verification letter is needed with specific details.)
I
agree that my typed/electronic signature as entered below is the legal equivalent of my manual signature on this application.
S
ignature of Applicant: Date:
Social Security Number ______________________ Email Address:__________________________________
Legal
Name of Applicant:___________________________________________ Date of Birth:___________________
Check here if requesting name change; must match social security card & driver’s license submitted.
Address: _____________________________________________________________________________
(Street) (City) (State) (Zip Code)
P
hone: (____) ________________ LA Certificate #: ____________ Payment Confirmation # __________________
(Provide email confirmation or screenshot of payment with documents)
Professional Conduct Form
ANSWER ALL QUESTIONS
Check
YES NO
1. Have you ever had any professional license/certificate denied, suspended, revoked,
or voluntarily surrendered?
If YES, in which state?____________________________
2. Are you currently being reviewed or investigated for purposes of such action as stated
in #1 or is such action pending?
If YES, in which state?_____________________________
3. Have you ever been convicted of any felony offense, been found guilty or entered a
plea of nolo contendere (no contest), even if adjudication was withheld?
If yes, please provide the following information:
Date of Conviction: ____________________
State of Conviction: ________ Court Jurisdiction of Conviction: ______________________
4. Have you ever been convicted of a misdemeanor offense that involves any of the
following:
a. Sexual or physical abuse of a minor child or other illegal conduct with a minor child.
b. The possession, use, or distribution of any illegal drug as defined by Louisiana or federal
law.
5. Have you ever been granted a pardon or expungement* for any offense as stated in #3 or #4?
NOTICE---EXPUNGEMENTS, FIRST OFFENDER PARDONS, PRE-TRIAL DIVERSIONS: Criminal
Background Checks (CBCs) conducted for purposes of employment will be conducted in accordance
with La. R.S. 17:15 and La. R.S. 15:587.1. Pursuant to Louisiana law R.S. 15:587.1., background
checks shall disclose ALL ARRESTS, COURT ACTION and CONVICTIONS, (Including but not limited to
expungements, first offender pardons and pre-trial diversion), and a copy of the report shall be provided
to the Louisiana Department of Education (LDE), in addition to the potential employer or LA Education
Agency (LEAs)s.
*Per BESE policy set forth in Bulletin 746, Louisiana Standards for State Certification of School Personnel, Section 903.C,
“failure to disclose actions such as first offender pardons, pre-trial diversion, expungements, etc. is grounds for
certification denial and/or revocation.”
If you answered “YES” to any questions, #1 through #5, you must provide court certified copies of all documents and
proceedings, civil records of Federal, State and/or District School Board actions, or other relevant documents that provide
full disclosure of the nature and circumstances of EACH separate incident in your application packet.
I aff
irm and declare that all information given by me in the responses to items #1 through #5 above is true,
correct, and complete to the best of my knowledge. I understand that any misrepresentation of facts, by
omission or addition, may result in criminal prosecution and/or the denial or revocation of my teacher certificate.
I agree that my electronic, typed signature as entered below is the legal equivalent of my manual signature on
this document.
SIGNATURE OF
APPLICANT:
Rev. August 1, 2021
APPLICANT’S
LEGAL NAME:
SSN:
ADDRESS:
(Street Address, Including City, State, Zip)
DATE OF
BIRTH:
MM/DD/YYYY
(No
Dashes)
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CERTIFICATION AND EXAM VERIFICATION APPLICATION (Teach Louisiana)

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Completed 13 January 2022

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