Application for State Certification

APPLICATION FOR STATE CERTIFICATION

NEW JERSEY STATE DEPARTMENT OF EDUCATIONCERTIFICATION (TEACHERS, SCHOOL LEADERS, EDUCATIONAL SERVICES PERSONNEL)

RIDER UNIVERSITY STUDENT INFORMATION
BRONC ID #: PROGRAM: Select one:GLTPGraduateUndergraduateTEACHFirst Class COMPLETION DATE (SEMESTER/YR): Select one:FALLSPRINGSUMMER ISUMMER II Select one:2014201520162017201820192020 ADVISOR (LAST NAME):
LAST NAME: / FIRST NAME: / MAIDEN NAME (if applicable): / MIDDLE INITIAL: / Gender:
MALE FEMALE
CELL PHONE #: / HOME/ALT PHONE#: / SOCIAL SECURITY #: / DATE OF BIRTH: / RACE(OPTIONAL):
Select one:UnknownAfrican AmericanAsianMexican AmericanPuerto RicanOther - HispanicNative AmericanNative HawaiianWhite
STREET ADDRESS:
CITY: / STATE:
ZIP: / EMAIL (non-Rider):
ARE YOU A CITIZEN OF THE UNITED STATES? YES NO IF NO, HAVE YOU FILED A DECLARATION OF INTENTION? YES NO
YES NO HAVE YOU EVER HAD A CERTIFICATE REVOKED OR SUSPENDED IN THIS OR ANY OTHER STATE?
YES NO HAVE YOU EVER BEEN CONVICTED OF A CRIME IN THIS OR ANY OTHER STATE?
CERTIFICATION(S) FOR WHICH YOU ARE APPLYING[You can only apply through Rider for certification programsenrolled in/completedthrough Rider.]
TEACHERS
Bilingual/Bicultural
Business (Comprehensive)
Early Childhood (P-3)
Elementary (K-6)
English
ESL
Marketing
Mathematics
Music
Reading
Social Studies
Students with Disabilities / Foreign Languages:
French
German
Spanish
Elementary Education with
Middle School Subject Matter Specialization (5-8):
Language Arts/Literacy
Math
Science
Social Studies / Sciences:
Biology
Chemistry
Earth Science
OTHER / SCHOOL LEADERS
Principal
School Administrator
School Business Administrator
Supervisor
EDUCATIONAL SERVICES PERSONNEL
Reading Specialist
SAC
School Counselor
School Psychologist
TEACHING EXPERIENCE (excludes substitute teaching and internships/practicum)
DO YOU HAVE ANY TEACHING EXPERIENCE? YES NO DO YOU CURRENTLY HOLD A VALID TEACHER’S CERTIFICATE (CE, CEAS, Standard)? YES NO
IF YES, LIST HIGHEST LEVEL OF EACH CURRENT CERTIFICATE HELD:
DO YOU HOLD A VALID STANDARD CERTIFICATE IN ANOTHER STATE? YES NO IF YES, ATTACH A COPY OF EACH OUT OF STATE CERTIFICATE HELD.
EDUCATIONAL OR WORK EXPERIENCE (LAST 2 POSITIONS). BEGIN WITH PRESENT. [NOTE: You may include substitute teaching (not student teaching). If you have never held a teaching position, complete for positions you have held even if it is not in the education field.]
POSITION HELD: (optional for UGs) / FROM (DATE): / TO (DATE): / EMPLOYER: (include County & District)
BRIEF DESCRIPTION:
POSITION HELD: (optional) / FROM (DATE): / TO (DATE): / EMPLOYER: (include County & District)
BRIEF DESCRIPTION:
THIS SECTION IS FOR ADMINISTRATIVE USE ONLY
DATE APPLICATION REC’D / TOTAL STATE FEE(S) PAID / METHOD OF PMT: [ ]CASH [ ]CHECK [ ]MONEY ORDER / NUM:
[ ]VI [ ]MC [ ]AMEX [ ]DISC NUM: * / EXPIRATION: /
TLAP PROFILE / OTHER FEE(S) PAID (if appl.) / METHOD OF PMT: [ ] CASH [ ] CHECK [ ]MONEY ORDER / NUM:
[ ]PRE-EXISTING [ ]NEW / [ ]VI [ ]MC [ ]AMEX [ ]DISC NUM: * / EXPIRATION: /
COLLEGE RECORD (INCLUDE ALL COLLEGES, MOST CURRENT COLLEGE FIRST) / COMPLETED PROFESSIONAL EDUCATION PROGRAM?
(only list FINAL Cumulative GPA(s), where applicable)
NAME OF COLLEGE
RIDER UNIVERSITY / STATE
NJ / DEGREE/CERTIFICATION / YEAR / FINALGPA / YES NO
YES NO
YES NO
PRAXIS MULTI- SUBJECT AND/OR CONTENT KNOWLEDGESCORES (WHERE APPLICABLE)
LIST ALL RELEVANT PRAXIS TESTS AND SCORES. DO NOT INCLUDE PRAXIS CORE EXAMS CHECK if N/A (not applicable for the certification(s) you seek).
(Please attach a copy of your ‘Test Taker Score Report’ reflecting test(s)/score(s), if not already provided to the Office of Field Placement and State Certification. [Note: The ‘‘Institution’ copy you may have had sent to Rider does not include all relevant information. The Test Taker/Examinee Score Report must include your SS# and it must indicate the NJ Department of Education (Code# R7666) as a Score Recipient for the NJ DOE to successfully match your score(s) to this application.]
TEST DATE / TEST CODE / TEST NAME [For multi-subj. sub-test scores (ie ElemEd), list each test/score on a single line and check only if passed all 4 parts.] / HIGHEST SCORE / PASSED / WAS THIS A
TEST RETAKE
YES NO / YES NO
YES NO / YES NO
YES NO / YES NO
YES NO / YES NO
YES NO / YES NO
WPT & OPI TESTS (FOR LANGUAGE CERTIFICATIONS ONLY, WHERE APPLICABLE)
LIST ALL RELEVANT LTI OPI/WPT TESTS. CHECK if N/A (not applicable for the certification(s) you seek).
WPT and/or OPI / LANGUAGE (if more than four tests, you can list WPT/OPI tests together, by language) / HIGHEST SCORE / PASSED
Select one:OPIWPTOPI and WPTSCHEDULEDTO BE SCHEDULEDNONE / Select one:SuperiorAdvanced HighAdvanced MidAdvanced LowIntermediate HighIntermediate MidIntermediate LowNovice HighNovice MidNovice LowPending Re-takePending ScorePending / YES NO
Select one:OPIWPTOPI and WPTSCHEDULEDTO BE SCHEDULEDNONE / Select one:SuperiorAdvanced HighAdvanced MidAdvanced LowIntermediate HighIntermediate MidIntermediate LowNovice HighNovice MidNovice LowPending Re-takePending ScorePending / YES NO
Select one:OPIWPTOPI and WPTSCHEDULEDTO BE SCHEDULEDNONE / Select one:SuperiorAdvanced HighAdvanced MidAdvanced LowIntermediate HighIntermediate MidIntermediate LowNovice HighNovice MidNovice LowPending Re-takePending ScorePending / YES NO
Select one:OPIWPTOPI and WPTSCHEDULEDTO BE SCHEDULEDNONE / Select one:SuperiorAdvanced HighAdvanced MidAdvanced LowIntermediate HighIntermediate MidIntermediate LowNovice HighNovice MidNovice LowPending Re-takePending ScorePending / YES NO
Incomplete applications will not be processed.
COMPLETE AND SIGN THE SECTIONS BELOW IN THE PRESENCE OF A NOTARY PUBLIC.
You will need a valid, state-issued, picture ID (ie driver’s license).
APPLICANT ACKNOWLEDGEMENTS
[______] I understand that it is my responsibility to ensure the state has received my Praxis scores in order for my certification(s) to be issued.
[______] I give permission to Field Placement/State Certification to request official Rider University transcripts for state certification purposes.
[______] I understand that Rider University cannot endorse my certification(s) with the state until my transcript is conferred, accordingly.
[______] I understand that I must apply directly with the state for additional certifications (for programs not enrolled in/completed through Rider).
[______] I understand that I must complete a state-generated survey (emailed to me by the state) before the state will ‘issue’ my certification(s). [______] I understand that it can take up to nine weeks (after the close of the semester) for my certification(s) to be ‘issued’ by the state (TLAP).
[______] GRs ONLY: I understand that I must provide Field Placement/State Certification an unofficial copy of my conferred, undergrad transcript(s).
[______] GRs ONLY: I understand that I must complete a Graduation Clearance Form for Terri Podgorski in order to be cleared for certification.

PLEASE NOTE: The Oath of Allegiance below is only valid for a six-month time period. Should you have a program completion delay, you will need to make another certification appointment to complete a new application and Oath.

New Jersey State Department of Education Office of Certification and Induction OATH OF ALLEGIANCE / VERIFICATION OF ACCURACY
UNITED STATES CITIZEN OATH OF ALLEGIANCE*
I, ______do solemnly swear, (or affirm) that, I will support the Constitution of the United States
and the Constitution of the State of New Jersey and that I will bear true faith and allegiance to the same and to the governments established in the United States and in this State, under the authority of the people, so help me God.
Certification Failure to complete these items will result in rejection of the candidate’s application for certification.
1.Have you ever been convicted of, pled guilty, no contest or nolo contendere to, or had adjudication withheld to a crime or offense, including DUI, in New Jersey or any other state or jurisdiction? If yes, complete and submit a Criminal/Offense Information Form.
YES NO
2. Have you ever had an education or other professional certificate, license or credential revoked, suspended, invalidated or denied for cause in New Jersey or any other state or jurisdiction?*YES NO
3. Have you ever surrendered or relinquished an education or other professional certificate, license or credential in New Jersey or any other state or jurisdiction? * YES NO
4. Are you the subject of any pending action or proceedings against your education or other professional certificate(s), license(s) or credential(s) in New Jersey or any other state or jurisdiction? * YES NO
5. Have you ever resigned, retired or been dismissed or suspended from an education-related position in New Jersey or any other state or jurisdiction following allegations of misconduct? * YES NO
6. Are you the subject of any civil, criminal or administrative investigation in New Jersey or any other state or jurisdiction? *
YES NO
* If any answer to Questions 2 through 6 is “yes,” complete and submit an Additional Information For the Oath of Allegiance Form.
PROOF OF ID (legal, picture ID):
State Expiration Date
DL# / VERIFICATION OF ACCURACY:
I certify that all statements and information provided herein are true and accurate.
______
APPLICANT SIGNATURE Date
NOTARY SEAL / SWORN AND SUBSCRIBED TO BEFORE ME this day:
______
NOTARY SIGNATURE Date
NON-CITIZEN / YOU MUST COMPLETE A NON-CITIZEN OATH OF ALLEGIANCE AND AN AFFIDAVIT OF INTENT TO BECOME A CITIZEN. ENCLOSED YES NO