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
VERIFICATION OF PROGRAM
COMPLETION AND CHARACTER
ALL SECTIONS must be completed. Send it to the institution/organization* where you completed your teacher preparation and certification
program. This form, when returned to you, is to be included with your application packet.
*If you were trained outside the U.S. and Canada, use Form SPI 4030 instead of this form.
SECTION A
TO BE COMPLETED BY APPLICANT
1. NAME LAST FIRST MIDDLE MAIDEN/FORMER NAME
2. ADDRESS 3. DATE OF BIRTH
CITY/STATE/ZIP 4. SOCIAL SECURITY NO. (OPTIONAL)
5. TELEPHONE:
( )
HOME
( )
6. E-MAIL
SECTION B
TO BE COMPLETED BY COLLEGE/UNIVERSITY
The above named is an applicant for teacher certification in Washington State. To be valid, this form must be signed by the program director of the
organization or the dean of the college or school of education, the certification officer, the chair of the education department, or the dean’s designee at
the institution where the applicant completed his/her teacher preparation and certification program. A stamped signature must be initialed by the person
using the stamp. RETURN THIS FORM TO THE APPLICANT.
A. Has this applicant completed your state-approved teacher education program?
A.
NO
NOD. Was he/she eligible for certification in your state at the completion of the teacher preparation program?
If no, what were the deficiencies?
Area in which applicant is recommended for certification. Please indicate area and grade level(s).
F.
Other approved content area/endorse-
ment programs that applicant has
completed:
D.
By signing this form I
attest that the above
information is true and
accurate to the best of
my knowledge.
NAME OF INSTITUTION/ORGANIZATION DATE
ADDRESS
CITY/STATE/ZIP
TELEPHONE
E-MAIL
(
NAME (PRINTED) AND TITLE (Program Director of Organization/Chairperson/Dean of Education Department/
Certification Office)
If no, what were the deficiencies?
)
G.
Do you have knowledge that the applicant has been arrested, charged, or convicted of any crime or has a history of any serious
behavioral problems?
YES
NO
List any reason(s) this applicant should not be certified in Washington.
SIGNATURE
For F & G, please note: In order to qualify for an endorsement area, the applicant must have completed an approved program in that
area. Each endorsement program must include coursework in methodology for that content area and completion of a supervised,
classroom-based field experience/internship that includes instruction in that content area.
AREA
AREA
Date of program completion.
B.
Did the applicant complete a supervised student teaching and/or internship as part of the program?
NO
B.
C.
NO
C.
Did the program include a defined course of study?
E.
RETURN COMPLETED FORM TO THE APPLICANT
FORM SPI/CERT 4020E (Rev. 5/18)
