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 ALTERNATIVE CERTIFICATION
PROGRAM/PATHWAY COMPLETION AND CHARACTER
Complete Section A of this form. Send it to the state agency or school district through which you completed your teacher
preparation and certification program or pathway. This form, when returned to you, is to be included with your application
packet.
*If you were trained outside the U.S. and Canada, use Form SPI 4030 instead of this form.
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:
BUSINESS
HOME
6. E-MAIL
SECTION B
TO BE COMPLETED BY INSTITUTION/AGENCY
The above named is an applicant for teacher certification in Washington State. Complete information in Section B. To be valid, this
form must be signed by the certification officer, the superintendent, or the superintendent’s designee at the institution where the
applicant completed his/her teacher preparation and certification program or pathway. A stamped signature must be initialed by the
person using the stamp. RETURN THIS FORM TO THE APPLICANT.
A. Has this applicant completed your state-approved teacher education program or pathway?
Date of program completion.
A.
NO
NO
D. Was he/she eligible for certification in your state at the completion of the teacher preparation program?
If no, what were the deficiencies?
E. Area in which applicant is recommended for certification. Please indicate area and grade level(s).
F. Other approved content area/endorse-
ment programs that applicant has
completed:
D.
By signing this form I attest
that the above information
is true and accurate to the
best of my knowledge.
NAME OF INSTITUTION/AGENCY DATE
ADDRESS
CITY/STATE/ZIP
TELEPHONE
E-MAIL
NAME (PRINTED) AND TITLE (Certification Officer)
Did the program/pathway include a supervised internship?
G. Do you have knowledge that the applicant has been arrested, charged, or convicted of any crime or has a history of any serious
behavioral problems?
YES
NO
List any reason(s) this applicant should not be certified in Washington.
SIGNATURE
For E & F, please note: In order to qualify for an endorsement area, the applicant must have completed an approved program in that
area. Each endorsement program must include coursework in methodology for that content area and completion of a supervised,
classroom-based field experience/internship that includes instruction in that content area.
AREA
AREA
B.
NO
B.
Did the program/pathway include a defined course of study?C.
NO
C.
RETURN COMPLETED FORM TO THE APPLICANT
FORM SPI/CERT 4020E-1 (Rev. 5/18)
