Educators Renewal Form

EDUCATORS RENEWAL FORM

Use this form to apply for renewal of an educator certificate or license. Complete all sections accurately and sign the certification at the end. Submission of false information or omission of required documentation may result in denial of renewal, revocation of privileges, or other administrative action as permitted by applicable licensure rules.

Educator Information

Date of Birth:    Certification/License No.:

Employee/Staff ID:    Phone:

Renewal Details

Renewal Type (check all that apply):

Standard Renewal (Professional)    Conditional Renewal    Temporary/Emergency

Requested Effective Date:    Requested Validity (years):

Professional Development and Compliance

I confirm completion of required professional development and mandatory trainings as indicated below. Enter supporting details in the fields provided. Retain supporting documentation for verification; the licensing authority may require submission upon request.

Total Professional Development Hours Completed:

Criminal background check on file with current employer or licensure body    Background Check Date:

CPR/First Aid certification on file    Expiration Date:

Mandated Reporter training completed as required

Employer Verification (optional)

If an employer representative will verify employment or training records, complete the following:

Declarations and Acknowledgements

By signing this form, I certify under penalty of perjury that the information provided is true, complete, and accurate to the best of my knowledge. I authorize the licensure authority and my employer to verify employment, training, and criminal history records as necessary to process this renewal. I further understand that knowingly submitting false information may subject me to administrative sanctions, including denial or revocation of licensure and other penalties permitted by law.

I acknowledge that renewal processing may require submission of documentary evidence and that failure to provide requested documentation within the timeframes specified may result in delay or denial of renewal.

I certify the foregoing and authorize verification as described above.

I understand that providing false information may lead to disciplinary action including denial or revocation of certification.

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