Hope College Teacher Education Program
Consent for Criminal Background Check and
Applicant Statement Regarding Criminal History
1. Name (Please Print): ____________________________________________________
First Middle Last
2. Student ID Number:____________________
3. Statement Regarding Criminal History:
Yes No
a. Have you ever been convicted of or pled no contest to a felony or misdemeanor?
b. Do you currently have any charges pending?
c. Have you ever had a teaching certificate or other professional license denied,
revoked, nullified, or surrendered?
If you answered Yes to any of the above questions, you will need to do the following:
Make an appointment with the Chair of the Education Department and Director of Certification.
Submit a copy of the Judgment of Sentence or
Register of Actions from the court to the Director of
Certification.
Submit a typed letter (dated and signed) addressed to the Michigan Department of Education (which
includes all the information listed below) to the Director of Certification:
1) Name and current address
2) Social Security number
3) Full date of birth
4) Date of conviction
5) Name and location (of the courthouse) where the conviction took place
6) Circumstance/letter of explanation regarding the conviction
7) Any information the candidate wishes to have accompany the recommendation
(including what the candidate learned from the experience)
Recommendations for a teaching certificate from colleges/universities are handled separately by the Michigan
Department of Education (MDE) for candidates with a conviction. If the conviction is judged by the MDE to
not adversely affect the candidate’s suitability to teach, s/he will receive an invoice for the certification fee and
subsequently a teaching certificate once payment is received. If the conviction is deemed to require additional
review, the candidate will receive correspondence from the MDE for a compliance conference. This process
may delay or even prevent teacher certification for the candidate.
4. Understandings and Agreements
a. I understand that I will be asked to consent and submit to the performance of a
criminal background check during the semester prior to student teaching.
b. I understand and agree that, if the criminal background check does not confirm
the statements above (3a-3c), my acceptance in the Hope College Teacher Education
Program will be rescinded unless and until I can prove that the information is incorrect.
c. I further understand that an individual who knowingly provides false information regarding
criminal conviction in this statement may be subject to civil or criminal penalties.
Signature:__________________________________________ Date:_____________________
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