Fill and Sign the Bir Form 2000 Documentary Stamp

APPLICATION FOR CREDENTIAL AUTHORIZING PUBLIC SCHOOL SERVICE (For Privacy Act Notification see Application Instructions) Mail application and payment (check or money order) to: Commission on Teacher Credentialing Certification Division 1900 Capitol Avenue Sacramento, California 95811-4213 APP  Appeal:__________________ Route to: ________________  IHE/County/District Use Only Commission Use Only: Fee Information FP Other Issuance Date:___________________BBBBBB___ Email Address:_______________BBBBBB____ CTC Use Only 1. PERSONAL INFORMATION (type or print) Social Security or Individual Tax ID Number: Date of Birth: (mm/dd/yyyy) Applicant’s Name: First Middle Last IHE/County/District Use County of Employment: Only All Former/Maiden Name(s): Address: City: State: Home Phone: Work Phone: Email Address: 2. CREDENTIAL TYPE Zip: Issuance Message Phone: Date:__________________ E-Mail Address: ________________ CCTC Use Only (choose only one type below) OPTIONS: Substitute Permits (PT) English Learner Authorizations Single Subject (Secondary Teaching) BILINGUAL AUTHORIZATION – Specify Language Specify Subject (If you are requesting more than one subject, enter it in Services Credentials Comments.) Term Specify World Language other than English (if applicable) Specify Other Health Services English Learner Authorization Term BILINGUAL AUTHORIZATION – Specify Language Multiple Subject (Elementary Teaching) English Learner Authorization Term Child Development Permits (PK) School-Age Emphasis Designated Subjects (PW) BILINGUAL AUTHORIZATION – Specify Language Subject(s) Term Education Specialist (Special Education) (If you are requesting more than one specialty area, enter it in Comments.) Supplementary Authorization(s) (PJ) Specify Specialty Area Subject Matter Authorization(s) (PJ) English Learner Authorization Other Specialist Credentials Term CTC Use Only Added Authorizations (AASE) FORM 41-4 (REV. 5/14) 1 3. CHILD DEVELOPMENT PERMIT RENEWAL SELF-VERIFICATION As the holder of a Child Development Permit (any level except the Associate Teacher Permit) you must complete a specific number of planned and approved professional growth activities for each five-year renewal. These activities must be recorded on the Professional Growth Plan and Record form. As the holder of a Child Development Permit choosing to self-verify completion of these requirements, you may be subject to an audit. The Commission reserves the right to request submission of these forms for auditing purposes any time within one year following submission of this application. If the Commission determines through its audit that you did not complete the professional growth requirements, your permit will not be renewed and you may be subject to adverse action on other credentials you currently hold. You must retain your Professional Growth Plan and Record form for one year following the submission of this application. DECLARATION: I certify (or declare) that I have read the above and completed the following for this renewal of my clear credential: I have completed __________ hours of professional growth activities My Professional Growth Advisor is ___________________________________________ Advisor’s Name ____________________________ Advisor’s Phone Number 4. PROFESSIONAL FITNESS QUESTIONS Answers to the following questions are required. If you answer yes to any question, you must complete the corresponding Professional Fitness Explanation Form. Before granting your application, the Commission will review, at a minimum:        Federal Bureau of Investigation criminal history (rap sheet) California Department of Justice criminal history (rap sheet) International database of teacher misconduct maintained by the National Association of State Directors of Teacher Education and Certification (NASDTEC) Previous reviews by the Commission Complaints from others Notifications from school districts Teacher preparation test score violations You must disclose misconduct, even if:       It happened a long time ago It happened in another state, federal court, military or jurisdiction outside the United States You did not go to court and your attorney went for you You did not go to jail or the sentence was only a fine or probation You received a certificate of rehabilitation Your conviction was later dismissed (even if under Penal Code section 1203.4), expunged, set aside or the sentence was suspended Warning: Failure to disclose any information requested is falsification of your application and the Commission may reject or deny your application or take disciplinary action against your credential. Do you understand:  these instructions and;  that you will later declare under penalty of perjury that the information you give is true and correct and;  the Commission may reject your application if it is incomplete and;  the Commission may deny your application or take disciplinary action against your credential if you do not disclose misconduct? Yes FORM 41-4 (REV. 5/14) No 2 a. Have you ever been:  dismissed or,  non-reelected or,  suspended without pay for more than ten days, or  retired or,  resigned from, or otherwise left school employment because of allegations of misconduct or while allegations of misconduct were pending? Yes No b. Have you ever been convicted of any felony or misdemeanor in California or any other place? You must disclose:  all criminal convictions  misdemeanors and felonies  convictions based on a plea of no contest or nolo contendere  convictions dismissed pursuant to Penal Code Section 1203.4  driving under the influence (DUI) or reckless driving convictions  no matter how much time has passed You do not have to disclose:  misdemeanor marijuana-related convictions that occurred more than two years prior to this application, except convictions involving concentrated cannabis, which must be disclosed regardless of the date of such a conviction.  infractions (DUI or reckless driving convictions are not infractions) Yes No c. Are you currently the subject of any inquiry or investigation by any law enforcement agency or any licensing agency in California or any other state? Yes No d. Are any criminal charges currently pending against you? Yes No e. Have you ever had any credential, including but not limited to, any Certificate of Clearance, permit, credential, license or other document authorizing public school service, revoked, denied, suspended, publicly reproved, and/or otherwise subjected to any other disciplinary action (including an action that was stayed) in California or any other state or place? Yes FORM 41-4 (REV. 5/14) No 3 f. Have you ever had any professional or vocational (not teaching or educational) license revoked, denied, suspended, and/or otherwise subjected to any other disciplinary action (including an action that was stayed) in California or any other state or place? Yes No Before submitting, please review the application for completeness: 1) 2) 3) 4) Personal information with correct SSN, date of birth, and email address filled in on page 1 Type of credential clearly marked on page 1 (use box below for additional subject/authorization requests) All Professional Fitness Questions marked Yes or No on pages 2 and 3 Payment (check or money order attached to the front of this form). See Credential Leaflet CL-659 for fee schedule. Checks or money orders may be made payable to the Commission on Teacher Credentialing. The Commission does not accept cash payments. All application fees are non-refundable. Applications that are submitted incomplete or without the appropriate fee included will not be processed and will be returned. 5. OATH AND AFFIDAVIT I solemnly swear (or affirm) that I will support the Constitution of the United States of America, the Constitution of the State of California, and the laws of the United States and the State of California. I hereby certify (or declare) under penalty of perjury under the laws of the State of California that all the foregoing statements in this application are true and correct. Date _________________ City ____________________________________________ County ____________________ State ______ SIGNATURE OF APPLICANT __________________________________________________________________________________________ 6. EMPLOYING AGENCY INFORMATION This section must be completed for all credential, certificate, and permit types where service is restricted to an employing agency. County CDS Code _________________________________ School District CDS Code ______________________________ Charter School/Non-Public School or Agency/Statewide Agency Name ____________________________________________ Applications for Provisional Internship Permits, Short-Term Staff Permits, Limited Assignment Permits, and Emergency Permits (except 30-Day Substitute Teaching Permits), must be filed through the employing agency. Employers must have an annual Declaration of Need for Fully Qualified Educators on file with the Commission prior to the submission of any applications for Limited Assignment or Emergency Permits. Comments/Additional Subject Requests: FORM 41-4 (REV. 5/14) 4