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OFFICE OF SUPERINTENDENT OF PUBLIC INSTRUCTION
Professional Certification
OLD CAPITOL BUILDING, PO BOX 47200
OLYMPIA WA 98504-7200
(360) 725-6400 TTY (360) 664-3631
Web Site: http:/ /www.k12.wa.us/certification/
E-Mail: cert@k12.wa.us
INSTITUTIONAL VERIFICATION OF PROGRAM
COMPLETION AND CHARACTER
Complete Section A of this form. Send it to the education department or appropriate department of the
college/university where you completed your educational staff associate preparation program. This form, when
returned to you, is to be included with your application packet.
SECTION A
TO BE COMPLETED BY APPLICANT
1. NAME LAST FIRST MIDDLE
2. ADDRESS
CITY/STATE/ZIP
5. TELEPHONE:
( )
HOME
( )
SECTION B
TO BE COMPLETED BY COLLEGE/UNIVERSITY
MAIDEN/FORMER NAME
3. DATE OF BIRTH
4. SOCIAL SECURITY NO. (OPTIONAL)
E-MAIL
The above-named is an applicant for certification in Washington State. Complete information in Section B regarding this applicant.
To be valid, this form must be signed by the dean or certification officer of the college or the chair of the department at the institution
where the applicant completed his/her preparation program. A stamped signature must be initialed by the person using the stamp.
Verify the information with the school seal. RETURN THIS FORM TO THE APPLICANT.
A. Did the applicant complete your institution’s state-approved program or pathway for purposes of certification to serve in a K-12
school setting in that state?
NO
If “yes,” for which role? School Psychologist School Counselor
B. Date of program or pathway completion:
C.
Did the program or pathway include completion of a comprehensive examination relevant to the specialized role?
NO
D. Did the applicant complete a supervised internship as part of the program or pathway?
NO
E.
Did the program or pathway include a defined course of study?
NO
F. Was the applicant eligible to receive full certification for the specialized role in your state upon completing the program or
pathway?
NO
G. Are you aware of any reason(s) this applicant should not be certified in Washington? If so, please explain:
NAME OF COLLEGE/UNIVERSITY DATE
ADDRESS
COLLEGE SEAL
CITY/STATE/ZIP
This form must bear the college/university seal.
TELEPHONE E-MAIL
( )
SIGNATURE AND TITLE
SIGNATURE
FORM SPI/CERT 4098E (Rev. 4/18)
RETURN COMPLETED FORM TO THE APPLICANT
