May 2021
N
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
co
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
CertApplication@doe.nj.gov
and must have the signature of the Authorizing
Officer.
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
certification.
1. Has this candidate completed your state-approved educator preparation program? Yes
No
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/
dd/yyyy):
Score:
