CLAIMS APPLICATION Georgia Professional Standards Commission Revised February 2016

Transcription

1 CLAIMS APPLICATIO Georgia Professional Standards Commission Revised February 2016 For local unit of administration (LUA) use OL. Do OT submit to GaPSC unless indicated below OR there is a es response to any Affirmation Question. Please print in dark ink or type. All supporting documents should remain on file with the employing LUA. Certificate/License Requested: Transaction Requested: on-instructional Aide License Initial Paraprofessional License Renewal Support Personnel License Renewal of Expired License - submit to GaPSC through ExpressLane Clearance Certificate One-ear on-renewable (renewal credits not met) - $20 Fee Applies; submit to GaPSC through ExpressLane 1. Please use ALL CAPS to print your LEGAL AME. Last ame Mr. Ms. Dr. First ame Social Security umber or GaPSC Certification ID Mailing Address Middle ame Date of Birth (MM/DD/) City State Zip Code Primary Telephone Alternate Telephone Address (required): - Employing System ame: Hire Date: Requested Beginning Validity Date of Certificate/License: For Paraprofessional Certificate Only: Education Level High School Diploma or GED (Must have passed one of the paraprofessional assessments.) One year of college (Must have passed one of the paraprofessional assessments.) Two years of college (at least 60 semester hours) Associate s degree Three years of college Four years of college Bachelor s degree Master s degree Specialist degree Doctorate degree Assessment Information Passed GA Paraprofessional Test Date passed: Passed ETS (Praxis) Paraprofessional Test Date passed: Passed GACE Paraprofessional Test Date passed: ot Applicable Meets Education Requirements ALL APPLICATS continue to Page 2 (Affirmation Questions). If the answer to any of the Affirmation Questions is yes, DO OT issue the certificate. Send the Application and supporting documentation to the GaPSC at the above address or you may submit it through ExpressLane. Page 1 of 2

2 Applicant s ame: Please Print Last, First Middle SS or Cert ID: 2. Personal Affirmation: The applicant should enter a truthful "es" or "o" response to each of the following questions. All questions must have a response in order for the application process to continue. "ES" responses automatically open an investigation and require an attached explanation along with any additional supporting documentation. DO OT 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 THA 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 THA 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; Been granted first offender treatment without adjudication of guilt; Participated in a pre-trial diversion program; 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)? I affirm that all information is true and correct. I hereby give permission to the Professional Standards Commission to obtain copies of any criminal and personnel records relating to me which are held by any local, state or federal government agency or private entity. I authorize any such agency or entity to release those records to the Commission. Signature: Date: OTE: This application must be received by the GaPSC within 90 days of the date of signature. Moral Turpitude Crimes involving moral turpitude: Fraud or false pretenses in obtaining something of value Larceny or a misdemeanor theft by taking Larceny after trust Murder Soliciting for prostitutes Voluntary manslaughter Sale of narcotics or other illegal drugs Pattern of failure to file federal tax returns Criminal Issuance of a bad check Making a false report of a crime Crimes OT involving moral turpitude: Public drunkenness Driving under the influence Carrying a concealed weapon Unlawful sale of liquor Simple Battery and Simple Assault Misdemeanor criminal trespass Child abandonment Misdemeanor offense of escape Obstruction of a law enforcement officer (Misd.) Most traffic offenses Page 2 of 2

3 Georgia Professional Standards Commission Verification of Lawful Presence 200 Piedmont Avenue SE, Suite 1702, Atlanta, GA Please Use Black Ink or Type Please use ALL CAPS to print your legal name in the spaces indicated. Last ame Mr. Ms. Dr. First ame Middle ame Social Security umber or GaPSC Certification ID Date of Birth (MM/DD/) ou must submit the following with this form: 1. otarized O.C.G.A (e)(2) Affidavit (page 3 of this form) 2. A copy of an acceptable ID (see below) These documents may be sent by mail or uploaded through the Applications section of When uploading documents, please ensure that images are legible. Option 1: If you are a U.S. citizen, you must submit a copy of any OE of the following: An unexpired driver s license issued by a U.S. state, D.C., or certain U.S. territories An unexpired United States passport or passport card An unexpired United States military identification card Any document listed here: Option 2: If you are a legal permanent resident of the U.S., you must submit a copy of the following: An unexpired United States Permanent Resident Card (front and back) Option 3: If you are a qualified alien or non-immigrant under the Federal Immigration and ationality Act, you must submit a copy of OE of the following: An unexpired work authorization card I-94 documentation reflecting the I-94 number and expiration date AD a valid foreign passport A valid Certificate of Eligibility reflecting your SEVIS number AD a valid foreign passport For more information about required documents, please visit

4 ISTRUCTIOS FOR COMPLETIG AFFIDAVIT REQUIRED TO OBTAI CERTIFICATIO/LICESURE 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 otary 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. our 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. ou must submit to the GaPSC a copy of the signed, notarized affidavit and a copy of the ID you present to the notary. Detailed instructions are below: 1. Select a secure and verifiable document to verify your identity. Review the list of documents on page 1 of this form. Depending on your citizenship/immigration status, different documents are acceptable. ou must present the ID you have selected to the otary Public. ou must also submit a copy of this ID to the GaPSC. 2. Print out the affidavit (page 3 of this form). If the affidavit is not accompanying the GaPSC Application for Certification, please also print and complete page 1 of this form. 3. Complete the affidavit, BUT DO OT SIG IT AT THIS TIME. Initial OL OE of the options listed on the affidavit and described here: o Option 1 is to be initialed/selected by you if you are a United States citizen; or o 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 o 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: Fill in the type of ID (for example: Georgia driver s license, U.S. passport, etc.) that you will be presenting to the otary Public as proof of your identity. 4. Find a otary Public in your area. Check the yellow pages, the internet, or with a local business, such as a bank. 5. Bring your affidavit and the identification document(s) you selected (from the list on page 1) to appear before the otary Public. 6. Show the otary Public your ID (from the list on page 1) and state under oath in the presence of the otary 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 otary Public signs and dates the affidavit and lists when the notary commission expires. 8. Make a copy of the affidavit and the ID that you presented to the otary Public for your own records. 9. Submit the following to the GaPSC: A copy of the signed and notarized affidavit; and A copy of the ID you presented to the notary.

5 O.C.G.A (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 , 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 ationality 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 (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 , and face criminal penalties as allowed by such criminal statute. Executed in (city), (state). Signature of Applicant Printed ame of Applicant SUBSCRIBED AD SWOR BEFORE ME O THIS THE DA OF, 20 OTAR PUBLIC My Commission Expires:

6 Georgia PSC Employer Assurance Form Revised May Piedmont Avenue SE, Suite 1702, Atlanta, GA This form is to be used to verify current employment as a Georgia educator. 1. Applicant Information: Last ame Mr. Ms. Dr. First ame Middle ame Social Security umber or GaPSC Certification ID Date of Birth (MM/DD/) Sections 2, 3, & 4 must be completed by the employer. 2. Employment Verification: In submitting this form, I certify that all required background checks have been completed for this applicant and any violations of the Georgia Code of Ethics for Educators have been reported to the GaPSC. I also certify that the applicant is/will be working within the local unit of administration (LUA) I represent in a position requiring GaPSC certification and that the applicant is/will be employed by the LUA or by an outside agency contracted by the LUA to provide staffing or educational services. Employment is in the certification field of : Employment in this certificate field began on: (MM/DD/) 3. Transaction Request: I am requesting the following transaction(s) on behalf of the applicant listed above (check all that apply): First GA certificate (issue on-renewable if appropriate) Renewal- A PLP/PLG has been established and the educator is making adequate progress toward meeting the plan/goals? es o Upgrade Addition of a renewable field Conversion of an existing certificate Waiver Permit (Initial/Renewal) Issuance of an International Exchange Certificate Addition of the following on-renewable or Supplemental Induction field to an existing certificate: Field Code: (see reverse) In requesting a on-renewable certificate, the system/agency/school affirms that the applicant is the best qualified applicant available for the certificate field requested and understands that requirements specified by the GaPSC must be completed during the validity of the on-renewable certificate. Other unlisted transaction (please specify): 4. Employer Information: ame of Superintendent or authorized Central Office Designee (print/type) Signature Date Phone umber Address ame of Local Unit of Administration (School System/Agency/Private Institution) Initial if applicable: This is a virtual school based outside of Georgia. I certify that the applicant listed above will be working with Georgia students.

7 EMPLOER ASSURACE FORM ISTRUCTIOS Revised May 2017 ote: Please complete all forms legibly in black ink or type. The name and address sections should be completed in ALL CAPS. The Georgia PSC Employer Assurance Form should accompany all applications for certification when the applicant is employed or will be employed by a Georgia public or private school system/agency. This form is used for the following: To verify that the applicant is currently employed or will be employed in the listed system/agency and all required background checks have been completed; To exempt the applicant from the certification fee in some cases; and To request a Permit, International Exchange, Waiver, or on-renewable certificate. Be sure to indicate the field code and beginning validity date requested. When possible, this form should be submitted electronically through the employer s account on TEACHIG FIELDS Elementary Fields Birth Through Kindergarten 870 Early Childhood Education (P-5) 808 Early Childhood Sp Ed Gen Curriculum (P-5) 708 Middle Grades (4-8): Language Arts Mathematics Reading Science Social Science Secondary Fields (6-12) Agriculture 788 Behavioral Science 766 Biology 750 Business 783 Chemistry 752 Earth/Space Science 753 Economics 757 Engineering and Technology 769 English 730 Family/Consumer Science 790 Geography 759 Healthcare Science Technology Ed (HSTE) 619 History 755 JROTC: Air Force 643 JROTC: Army 641 JROTC: Marine Corps 644 JROTC: avy 642 Marketing 792 Mathematics 743 Physics 751 Political Science 756 Science (Broad Field) 748 Speech 733 Trade & Industrial Education: Architectural Drawing and Design 658 Audio/Video Technology & Film 652 Automotive Service Tech 650 Aviation 830 Barbering 613 Collision Repair 653 Computer Animation 678 Construction Cosmetology 525 Culinary Arts Distribution & Logistics 654 Electronics Technology 657 Esthetics 614 Government & Public Administration 680 Granite Technology 659 Graphic Communications & Design 660 IT/Info Services & Support 662 IT/etwork Systems IT/Programming & Software Dev. 664 IT/Cybersecurity 676 Manufacturing & Engineering Sciences 667 Marine Service Technology 618 ails 615 Precision Machine Technology 668 Law, Public Safety, Corrections & Security 670 Sheet Metal 671 Welding Technology 673 CERTIFICATE FIELD CODES Foreign Languages (P-12) American Sign Lang. 832 Arabic 845 Chinese (Mandarin) 834 Farsi 848 French 836 German 838 Greek (Classical) 842 Hebrew 841 Hindi 843 Italian 840 Japanese 831 Korean 846 Latin 835 Portuguese 844 Russian 839 Spanish 837 Swahili 847 Turkish 850 Urdu 849 Special Education (P-12) Consultative Sp Ed Adapted Curriculum 805 Behavior Disorders 778 Deaf Education 797 Sp Ed General Curriculum 798 ECE/Sp Ed General Curriculum (P-5 only) 708 Learning Disabilities 777 Physical & Health Disabilities 768 Sp Ed Preschool (ages 3-5) 799 Visual Impairment 722 Sp Ed Academic Content Concentrations: P Language Arts Mathematics Reading Science Social Science P-12 Fields Art 764 Computer Science 789 Dance 820 Drama 821 Eng. To Speakers of Other Lang. (ESOL) 885 Gifted (P-12) Consultative 780 Gifted Concentrations: Language Arts 963 Mathematics 961 Reading 965 Science 962 Social Science 964 Health Education Health and Physical Education 761 Music 767 Reading 732 SERVICE FIELDS (P-12) Audiology 801 Media Specialist 813 School Counseling School utrition Director 729 School Psychology 711 School Social Work 715 Speech and Language Pathology 802 Curriculum & Instruction 902 Instructional Technology 903 Teacher Leadership 904 LEADERSHIP FIELDS (P-12) Educational Leadership 704* Educational Leadership Building-Level 706* Educational Leadership System-Level 707* Educational Leadership-Tier I Educational Leadership- Tier II EDORSEMETS Teaching Endorsements: Autism 877 Birth Through Five 871 Career Exploration (PECE) 749 Career Technical Instruction (CTI) 810 Coaching Endorsement 980 Computer Science 882 Coordinated Career Academic Ed (CCAE) -770 Culinary Arts 884 Dual Immersion Early Childhood 863 ESOL 825 Gifted In-Field 881 Intervention Specialist 887 K-5 Mathematics 970 K-5 Science 971 Middle Grades 859 On-Line Teaching 898 Reading 833 Safety & Driver Education 763 Sp Ed Deaf Education 874 Sp Ed Physical & Health Disabilities 875 Sp Ed Preschool (ages 3-5) 826 Sp Ed Transition Specialist 873 Sp Ed Visual Impairment 876 Work-Based Learning 793 Service Endorsements: Student Support Team Coordinator 888 Teacher Support and Coaching 712 Leadership Endorsements: Teacher Leader 774 * Effective 1/15/16, field no longer issued