Fillable Initial Application for Educator Certification (Maryland State Department of Education)

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Initial Application for Educator Certification (Maryland State Department of Education)

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The Initial Application for Educator Certification (Maryland State Department of Education) form is 4 pages long and contains:

  • 1 signature
  • 19 check-boxes
  • 141 other fields

Country of origin: US
File type: PDF

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Initial Application for Educator Certification
Educator Profile
First Name:
Last Name:
Middle Initial
Maiden Name:
Last 4 Digits of Social Security Number
Date of Birth
Address:
City, State
Zip Code:
Email:
Home Phone:
Mobile Phone:
Race
Ethnicity
Gender (check appropriate code)
1. American Indian/Alaskan Native
2. Asian
1. Hispanic
2. Non-Hispanic
1. Male
2. Female
3. Black or African American
4. Native Hawaiian or Other Pacific Islander
5. White
Area/s of Certification Requested: ______________________________________
Education History
(List your complete educational history, whether or not a degree was conferred)
Institution Degree
Conferred
On* Major/Minor GPA
Initial
Teacher
Preparation
*Commencement is not a guarantee of conferral.
Rev. 08.03.2020
Supervised Student Teaching and/or Practicum
Location of School
City, State, Zip
Grade(s)/Subject(s) Taught
From (Mo/Yr)
To (Mo/Yr)
Out-of-State Certificates (Attach photocopies of all out-of-state certificates)
State
Valid Dates
Areas Certified to Teach
Employment History * (List in reverse chronological order)
Employer Position Start End Address
Subjects and Grades
Taught
*If additional space is needed, please attach supplemental sheets.
Rev. 08.03.2020
__________
Suspension/Revocation
Yes
Indicate name of state and date
No
1. Is action pending to suspend, revoke, or deny your certificate or
a
pplication for certification in another state? (A determination of academi
c
i
neligibility is not considered denial of a certificate.
)
☐
☐
2. Have you ever had a certificate or license revoked, suspended, voluntarily
s
urrendered or denied by any state? (A determination of academi
c
i
neligibility is not considered denial of a certificate.
)
☐
☐
3. Have you ever resigned or been dismissed after notice of allegations of
m
isconduct involving a student
?
☐
☐
4. Have you ever been convicted of, pleaded guilty or nolo contendere with
r
espect to, or received probation before judgment with respect to a cri
me
a
gainst children or a crime of violence*
?
☐
☐
5. Have you ever had a criminal history background check completed?
☐
☐
Please provide an explanation and relevant documentation if you identified a state and date for questions 1-4 above.
*If you are unsure whether a crime is a “crime of violence,” please err on the side of disclosure as filing false or misleadin
g
i
nformation on an application for certification may be grounds to deny a certification request. Crime of violence is defined in th
e
M
aryland Code Criminal Law Article Section 14-
101.
Affirmation Statement
Educator Testing
All Candidates applying for an initial educator certificate are required to present qualifying scores on the appropriate
certification tests, where applicable. Photocopies are acceptable.
Educator Transcript
Official transcripts of all college credits (original transcript in unopened mailer or student copy in unopened mailer) must
be submitted in order to process this application.
Fee Payment
A certification fee is required on initial applications for certification. You will receive a notification to submit your fee
payment when MSDE has confirmed your eligibility.
Affirmation Statement
I hereby affirm under the penalties of perjury that the information given by me in this application is true and complete
to the best of my knowledge and belief. I am aware that should investigation at any time disclose any misrepresentation
or falsification of a material fact, my application will be disapproved and/or my certificate will be rescinded.
I agree with the above affirmation statement and agree to abide by the consequences delineated above.
Initial Here
(Typed initials will not be accepted)
Rev. 08.03.2020
Privacy Notice
The principal purpose served by gathering the requested information is to provide necessary data and background
records for the Superintendent of Schools as required by state law and regulation.
The consequence of refusal to provide the requested information is non-issuance of a Maryland Certificate.
You have the statutory right to inspect, amend, or correct the requested information under State Government Article
§§10-611-10-629, Annotated Code of Maryland
.
T
he requested information is not generally available for public inspection, unless specifically authorized by law.
The requested information is not routinely shared with other governmental agencies; however, by accepting this notice
of privacy, I understand that local school systems will be able to review education records pertaining to my certification.
I hereby affirm, under the penalties of perjury, that the information given by me in this application is true, and
complete, to the best of my knowledge and belief. I am aware that should investigation at any time disclose any
misrepresentation or falsification of a material fact, my application will be disapproved and/or my certificate will be
rescinded.
Date:
_______________________________Signature: ______________________________________________
(Typed signatures will not be accepted)
If you need additional space to provide answers to questions from previous sections, please use the space provided below or attach
supplemental sheets.
Rev. 08.03.2020
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Initial Application for Educator Certification (Maryland State Department of Education)

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Completed 22 December 2020

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