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 PREPARATION/CERTIFICATION
PROGRAM ENROLLMENT
Complete Section A of this form. Send it to the education department of the college/university where you are currently
enrolled in your preparation and certification program. This form, when returned to you, is to be included with your
application packet.
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 certification in Washington State. Complete information in Section B regarding this applicant.
To be valid, this form must be signed by the dean of the college or school of education, the certification officer, the chairman of the
education department, or the dean’s designee at the institution where the applicant is currently enrolled in his/her preparation and
certification program. A stamped signature must be initialed by the person using the stamp. Verify the information with the school
seal. RETURN THIS FORM TO THE APPLICANT.
A.
Is the applicant currently enrolled in your state-approved preparation and certification program?
A.
NO
B.
Is this a teacher or principal program?
Anticipated date of program completion.
State in which program is approved:
C.
Major area(s) in which applicant will be recommended:
D. Additional area(s) applicant may be eligible to be certified:
E.
Will the applicant be eligible for certification in the state in which the program is approved at the completion of
E.
NO
the program?
If no, what are/will be the deficiencies?
F. Do you have knowledge that the applicant has been
YES
List any reason you know of why this applicant should not be
arrested, charged, or convicted of any crime or has a
NO
certified in Washington.
history of any serious behavioral problems?
NAME OF COLLEGE/UNIVERSITY DATE
COLLEGE SEAL
This form must bear the
college/university seal.
ADDRESS
CITY/STATE/ZIP E-MAIL
TELEPHONE
SIGNATURE AND TITLE (Chairperson of Education Department/Certification Officer)
RETURN COMPLETED FORM TO THE APPLICANT
FORM SPI/CERT 4050E (Rev. 1/18)
