Fillable West Georgia College GaPSC Pre-Service Certificate Application

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West Georgia College GaPSC Pre-Service Certificate Application

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The West Georgia College GaPSC Pre-Service Certificate Application form is 3 pages long and contains:

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GaPSC Pre-Service Certificate Application
Please Use Black Ink or Type – Revised April 2015
This form must be submitted by an educator preparation provider. Candidates should not submit this form directly to the GaPSC.
1. Please use ALL CAPS to print your LEGAL NAME.
Last Name
First Name Middle Name
Social Security Number Date of Birth (MM/DD/YY) Telephone Number
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/
/
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Mailing Address
City State Zip Code
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Gender (check one) Ethnicity (check one)
Male Female Are you Hispanic or Latino of any race? Yes No
Race (check all that apply)
Asian
American Indian or Alaska
Native
Black or African
American
Native Hawaiian or Pacific
Islander
White
2. Personal Affirmation: The applicant should enter a truthful "Yes" or "No" response to each of the following questions.
All questions must have a response in order for the application process to continue. "YES" responses automatically
open an investigation and require an attached explanation along with any additional supporting documentation. DO
NOT include matters that the GaPSC has investigated or is currently investigating.
1. Have you ever had an adverse action (i.e. warning, reprimand, suspension, revocation, denial, voluntary
surrender, disbarment) taken against a professional certificate, license or permit issued by an agency OTHER
THAN the Georgia Professional Standards Commission?
2. Are you currently the subject of an investigation involving a violation of a profession’s laws, rules, standards or
Code of Ethics by an agency OTHER THAN the Georgia Professional Standards Commission?
3. Have you ever received a less than honorable discharge from any branch of the armed services? (If “yes”, provide
a copy of form DD214.)
4. While under investigation, have you ever left an employment position (retired, resigned, been dismissed,
terminated, non-renewed or otherwise)?
5. Are you currently the subject of an investigation involving sexual misconduct or physical harm to a child?
6. Are you the subject of a pending investigation involving a criminal act?
7. For any felony or any crime involving moral turpitude, have you ever:
♦ Pled guilty;
♦ Entered a plea of nolo contendere;
♦ Been found guilty;
♦ Pled guilty to a lesser offense;
♦ Participated in a pre-trial diversion program;
♦ Been granted first offender treatment without
adjudication of guilt;
♦ Been found not guilty by reason of insanity; or
♦ Been placed under a court order whereby an
adjudication or sentence was withheld?
8. Have you ever been convicted, or pled to a lesser offense for any sexual offense?
9. Have you been convicted of a drug offense (felony or misdemeanor)?
Consent:
I hereby authorize the Georgia Professional Standards Commission to receive any criminal history record
information pertaining to me which may be in the files of any state or local criminal justice agency in Georgia, and to
perform periodic criminal history background checks for the duration of my certification in the state of Georgia.
Signature: ______________________________________________________ Date: ______________________________
NOTE: This application must be received by the GaPSC within 90 days of the date of signature.
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
INSTRUCTIONS FOR COMPLETING VERIFICATION OF LAWFUL PRESENCE AFFIDAVIT
In order to obtain a certificate/license from the Georgia Professional Standards Commission (GaPSC), Georgia
law requires every applicant to complete an affidavit (sworn written statement) before a Notary Public that
establishes that the applicant is lawfully present in the United States of America. This affidavit is a material part of
your GaPSC certification/licensure application and must be completed truthfully. Your application may be denied
or your certificate may be revoked by the GaPSC if it is determined that you have made a material misstatement
of fact in connection with your application. Please follow the instructions listed below.
You must submit the following with your Pre-Service Application and GCIC Consent Form:
1. Notarized Affidavit (page 3 of this document)
2. A copy of an acceptable ID (see below)
1. Select the ONE option on the affidavit that applies to you:
Option 1 is to be initialed/selected by you if you are a United States citizen; or
Option 2 is to be initialed/selected by you if you are a legal permanent resident of the United States: you
are not a U.S. citizen but you have a green card; or
Option 3 is to be initialed/selected by you if you are a qualified alien or non-immigrant (but not a U.S.
citizen or a legal permanent resident).
If you selected Option 2 or 3, please provide the number (whether or not it is called an “alien number”)
issued by the Department of Homeland Security or other federal immigration agency in the blank space
following this statement: “My alien number issued by the Department of Homeland Security or other federal
immigration agency is:”
2. Select an acceptable ID based on your selection in Step 1.
Acceptable IDs for Option 1 (U.S. citizen) are:
o An unexpired driver’s license issued by a U.S. state, D.C., or certain U.S. territories
o An unexpired United States passport or passport card
o An unexpired United States military identification card
o Any document listed here:
http://www.gapsc.com/certification/downloads/SecureVerifiableDocuments.pdf
The only acceptable ID for Option 2 (legal permanent resident) is a copy of the front and back of your
unexpired United States Permanent Resident Card.
Acceptable IDs for Option 3 (qualified alien or non-immigrant) are:
o An unexpired work authorization card
o I-94 documentation reflecting the I-94 number and expiration date AND a valid foreign passport
o A valid Certificate of Eligibility reflecting your SEVIS number AND a valid foreign passport
Fill in the type of ID (e.g. Georgia driver’s license, U.S. passport, etc.) that you are using on the affidavit on
the line after “The secure and verifiable document provided with this affidavit can best be classified as:”
3. Print out the affidavit (page 4 of this document).
4. Find a local Notary Public. Check the yellow pages, the internet, or with a local business such as a bank.
5. Bring your affidavit and the ID you selected (from the list in Step 2) to appear before the Notary Public.
6. Show the Notary Public your ID and state under oath in the presence of the Notary Public that you are
who you say you are and that you are in the United States lawfully. Then sign your name.
7. Make certain that the Notary Public signs and dates the affidavit and lists when their notary
commission expires.
8. Make a copy of the affidavit and the ID that you presented to the Notary Public for your own records.
9. Submit the following with your Pre-Service Application and GCIC Consent Form:
A copy of the signed and notarized affidavit; and
A copy of the ID you presented to the Notary Public.
O.C.G.A. § 50-36-1(e)(2) Affidavit
By executing this affidavit under oath, as an applicant for a Georgia Educator Certificate/License, as
referenced in O.C.G.A. § 50-36-1, from the Georgia Professional Standards Commission, the undersigned
applicant verifies one of the following with respect to application for a public benefit:
1) _________ I am a United States citizen.
2) _________ I am a legal permanent resident of the United States.
3) _________ I am a qualified alien or non-immigrant under the Federal Immigration and Nationality Act
with an alien number issued by the Department of Homeland Security or other federal
immigration agency.
My alien number issued by the Department of Homeland Security or other federal
immigration agency is: ____________________.
The undersigned applicant also hereby verifies that he or she is 18 years of age or older and has provided at
least one secure and verifiable document, as required by O.C.G.A. § 50-36-1(e)(1), with this affidavit.
The secure and verifiable document provided with this affidavit can best be classified as:
_______________________________________________________________________.
In making the above representation under oath, I understand that any person who knowingly and willfully
makes a false, fictitious, or fraudulent statement or representation in an affidavit shall be guilty of a violation
of O.C.G.A. § 16-10-20, and face criminal penalties as allowed by such criminal statute.
Executed in ___________________ (city), __________________(state).
____________________________________
Signature of Applicant
____________________________________
Printed Name of Applicant
SUBSCRIBED AND SWORN
BEFORE ME ON THIS THE
___ DAY OF ___________, 20____
_________________________
NOTARY PUBLIC
My Commission Expires:
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West Georgia College GaPSC Pre-Service Certificate Application

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Completed 17 December 2019

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