Fillable Griffin RESA Endorsement Candidate Application Form

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Griffin RESA Endorsement Candidate Application Form

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Rev. 3/17
Griffin RESA
440 Tilney Avenue, Griffin, GA 30224
Endorsement Candidate Application Form
Endorsement (circle one): Coaching Gifted K-5 Math K-5 Science SST Coordinator Teacher Leader
Teaching Certification Number
Email Address
Date of Birth (mm/dd/yyyy)
Home Street Address
Home City, State, Zip
System & School
Grade Level(s)
Subject Area(s)
Gender
(for GaPSC statistical analysis only)
⃝ Female ⃝ Male
Ethnicity
(for GaPSC statistical analysis only)
⃝ American Indian ⃝ Asian ⃝ Black ⃝ Hispanic ⃝ Multi-Racial
⃝ White ⃝ Other
Immediate supervisor will be responsible for supervision of clinical practice.
____________________________________
__________________________________________
Principal/Supervisor Signature
System Director of Professional Learning or
Designee (required for District Pay applicants only)
Above signature(s) verify that candidate is recommended for this program and holds the appropriate
Georgia certification in order for the endorsement to be added. See program details for minimum years'
experience and/or any other admission criteria specific to each endorsement program.
Send your completed application along with a copy of your certificate to
professionallearning@griffinresa.net.
My signature below verifies my understanding that I will adhere to all program requirements, expectations, evaluation
guidelines, program completion expectations, processes, and procedures for the selected endorsement program. I have
completed all admission requirements as outlined in the program-specific advisement sheet.
________________________________________ __________________________________________
Candidate’s Signature Date
Candidate’s Legal Name
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Griffin RESA Endorsement Candidate Application Form

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Completed 6 August 2021

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