Fillable VIRGIN ISLANDS BOARD OF EDUCATION

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VIRGIN ISLANDS BOARD OF EDUCATION

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  • 11 check-boxes
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VIRGIN ISLANDS BOARD OF EDUCATION
St. Thomas Office
P.O. BOX 11900
Dronningens Gade Nos. 60B, 61 and 62
St.Thomas, V.I. 00801
Phone: (340) 774-4546
Fax: (340) 774-3384
St. Croix Office
1115 Strand Street
Suite 201-B
Christiansted, VI 00820
Phone: (340) 772-4144
Fax: (340) 772-2895
APPLICATION FOR CERTIFICATE
FOR TEACHERS, ADMINISTRATORS OR SPECIAL SERVICES
(Print all information in black ink)
PART 1: PERSONAL INFORMATION
LAST NAME: FIRST NAME MI
OTHER NAMES
SOCIAL SECURITY NUMBER
ADDRESS (P.O. BOX)
(City) (State) (Zip Code)
PHONE: E-MAIL ADDRESS:
(Home) (Work)
Enclose a NONREFUNDABLE application fee of $25 for Professional Educator Class I
or II Certificate and $10 for substitute Teacher Pool Certificate in the Form of a money
order, cashier’s check or certified bank check payable to V.I. Board of Education
Professional Staff Certification Application
Page 2 of 4
1. Have you ever been convicted of any crime, including sex crimes, moral
turpitude, and minor traffic violations? (Attach a copy of your Police Record from
last place of residence). YES NO
2. Have you ever been dismissed from a position in a public or nonpublic school or
childcare facility? YES NO
3. Have you ever had a teaching credential revoked, suspended, rejected, down
graded, or annulled in any state, territory or foreign country? YES NO
4.Have you ever surrendered a teaching credential in any state, territory or foreign
country? YES NO
NOTE: If you answed “YES” to any of the above questions, you must attach a
signed statement of explanation. Submit official copies of court or administrative
record(s) including disposition of each case.
Statement of Explanation:
Signature: _______________________________________ Date: _____________
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Professional Staff Certification Application
Page 3 of 4
LAST NAME FIRST NAME MI
PART II: CERTIFICATE (S) REQUESTED:
PART III EDUCATIONAL BACKGROUND
LIST THE NAMES OF COLLEGES OR UNIVERSITIES ATTENDED
PART IV: DO YOU HOLD A VALID OR EXPIRED CERTIFICATE? YES NO
STATE OF ISSUE TYPE OF CERTIFICATE
DATE OF EXPIRATION
(Attach a copy of both sides of your certificate.)
Name of
Institution
State
Year of
Graduation
College Credit
Degree Award
Check here if this is a re-certification.
Professional Staff Certification Application
Page 4 of 4
PART V: STARTING WITH THE MOST RECENT, LIST TEACHING,
ADMINISTRATIVE OR SPECIAL SERVICE EXPERIENCE (NOT STUDENT
TEACHING, SUBSTITUTE OR PARAPROFESSIONAL EXPERIENCE)
Name of
School
Location
(City, State)
Job Title
Subject/Field
Grade (s)
Dates Employed
From (M/Y) to
(M/Y)
Certification Application (Page 3 of 3)
PART VI: BRING YOUR ORIGINAL PROOF OF CITIZENSHIP, SOCIAL
SECURITY CARD & PICTURE IDENTIFICATION
PART VII: ATTESTATION
I herby certify that the information provided by me in this application contains no
willful misrepresentation or falsification and that all of the information given by me
is true, complete and accurate. I understand that this information may be verified and
that any misrepresentation or falsification may result in the non-issuance or
revocation of my certificate.
SIGNATURE OF APPLICANT: _______________________________________
DATE:_______________________
Information on this application is subject to release pursuant to the Freedom of
Information Act.
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VIRGIN ISLANDS BOARD OF EDUCATION

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Completed 19 May 2021

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