State of Florida
Voluntary Prekindergarten Education Program
Class Registration Application - Instructors
New Application
Updated Application & Date:
No Change
Form OEL VPK 11A (April 30, 2010) Page _____ of _____
6M-8.300, F.A.C.
Provider Name:
Program Year:
Employer Identification Number:
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1. Class ID: 2. Legal Name:
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5. Credential:
6. Curriculum:
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1. Class ID:
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1. Class ID:
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FS SS LS
C L G
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8. Cert:
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End Date:
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1. Class ID:
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1
Note: See the Privacy Act Statement concerning Social Security Numbers on page 2 of the instructions accompanying this application.
I certify that:
Each instructor listed above has submitted an attestation of good moral character, has provided documentation to be maintained in the files of
the PROVIDER/DISTRICT and the COALITION documenting that the individual has undergone a Level 2 background screening within the previous
five (5) years in accordance with section 435.04, F.S., including a federal (Federal Bureau of Investigation), state (Florida Department of Law
Enforcement), and local (county of the instructor’s residence) screening which demonstrates that the individual is not ineligible to act as a VPK
instructor; and is not ineligible to teach in a public school because the instructor’s educator certificate has been suspended or revoked;
Each credentialed instructor listed above has the credentials and emergent literacy training required for the VPK program; and
To the best of my knowledge and belief, the information provided is true and correct. If any information changes, the provider will notify the
coalition within 14 days. Changes implemented prior to receipt of coalition approval may result in noncompliance with VPK requirements.
11. Signature of Authorized Representative: By Electronic Signature
12. Date:
13. Print Name of Authorized Representative:
14. Daytime Phone Number:
Process Agent Date
Process Manager
Date
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