PROFESSIONAL FITNESS. Yes No 1. Have you ever held or do you currently hold a Washington education certificate? 2. Have you ever held or do you currently hold any education certificate, credential or license authorizing service in the public/private schools in another state, province, territory, or country? If “yes,” list the states, provinces, territories, and/or countries: 3. Are you currently or have you ever been the subject of any certificate or licensing investigation or inquiry by any certification or licensing agency for allegations of misconduct? If “yes,” on a separate sheet of paper, list the agency, including complete address and telephone number as well as the purpose of the investigation or inquiry. If you answer “yes” to questions 4 through 11 (Section II), on a separate sheet of paper, give a complete explanation, including duties, circumstances, and supporting documentation. 4. Have you ever had any adverse action taken on any certificate or license? (Adverse action includes letters of warning, reprimands, suspensions [including stayed], revocations, voluntary surrenders, or voidance.) 5. Have you ever been denied, or otherwise rejected for cause, an education certificate, credential, or license? 6. Have you ever withdrawn an application for any education certificate, credential, or license? 7. Have you ever practiced in any educational position in a public school for which you did not hold the appropriate valid educational certificate, credential, or license for that position? 8. Have you ever been dismissed, discharged, or fired from any employment position involving children or dependent adults? (Do not include RIFs) 9. Have you ever resigned from or otherwise left any employment (e.g., settlement agreement) while allegations of misconduct were pending? FORM SPI/CERT 4020B (Rev. 2/12) Page 1 of 4 OFFICE OF SUPERINTENDENT OF PUBLIC INSTRUCTION Professional Certification Office of Professional Practices Old Capitol Building, PO BOX 47200 OLYMPIA WA 98504-7200 OPP (000) 000-0000 TTY (000) 000-0000 Web Site: http:/ /xxx.x00.xx.xx/xxxxxxxxxxxxx E-Mail: xxxx@x00.xx.xx
