May 2021
ew Jersey Department of Education
Office of Certification and Induction
Verification of Preparation Program Completion
This form is submitted on behalf of a candidate who has
mpleted an educator preparation program. This form must
be sent directly from the university email address of the Authorizing Officer (Chairperson, Education Department/
Certification Officer) to the NJDOE at
and must have the signature of the Authorizing
Candidate Contact Information
Information submitted should match any other required documentation.
Last Name: First Name: Middle Name or Initial
Street Address:
City: State:
Zip Code:
Last Four Digits of Social Security Number: ***-**- Email Address:
Tracking Number
(If Known): Date of Birt
h (mm/dd/yyyy):
Phone Number:
College or University Verification
Complete questions one through five in reference to the candidate named above who is seeking New Jersey educator
1. Has this candidate completed your state-approved educator preparation program? Yes
a. If yes, please list date of completion (mm/dd/yyyy):
2. If the candidate is applying for teacher certification: Has the candidate completed and passed or was waived from
the state-approved teacher performance assessment (edTPA, Praxis Performance Assessment for Teachers (PPAT), or
another state-approved performance assessment)?
Yes No
a. If yes, please c
omplete the following:
Name of Assessment:
Test Date (mm/
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3. Was this candidate eligible for certification in your state at the completion of their educator preparation program?
a. If n
o, please list the reasons:
4. Certification area and/or grade level in which the applicant is recommended for:
5. Student Teaching, Clinical Practice, Internship and/or Practicum Experience
Course Title(s):
Course Number(s):
Grade Level/Setting: Number of Clock Hours:
Authorizing Information
Name of College/University:
eet Address:
Zip C
Daytime Telephone Number:
Title of Authorizing Officer:
E-mail of Authorizing Officer:
Signature of Authorizing Officer:
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