Cg 10 Application Form PDF Details

The CG 10 application form is the means by which individuals can apply for Canadian permanent residency. It is used to assess an individual's eligibility for residency and to ensure that they meet the requirements of the Immigration and Refugee Protection Act. The form must be completed in full, and all requested documentation must be provided, in order for an application to be processed. Incomplete or inaccurate submissions can result in delays or even rejection. so it is important to understand what information is required and how to complete the form accurately. This blog post will provide an overview of the CG 10 application form, including what information is requested and how to provide it. "So you're thinking about moving to Canada? Well congratulations! The country has a lot to offer – from

QuestionAnswer
Form NameCg 10 Application Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesCG-10, discolosure, YYYY, 2009

Form Preview Example

C G - 10 APPLIC ATIO N FO R A

FLO RIDA EDUC ATO R’S C ERTIFIC ATE

Flo rida De pa rtm e nt o f Educ a tio n

Bure a u o f Ed uc a to r C e rtific a tio n Ro o m 201, Turling to n Build ing 325 We st G a ine s Stre e t

Ta lla ha sse e , FL 32399-0400

 

O ffic ia l Use O nly

FLDO E Da te Sta m p

PA

 

 

 

PM

C K

C A

 

MO

VO

 

 

 

PN

 

 

 

AFF

 

Ye s

No

PERSO NAL INFO RMATIO N: Co m p le te e ntire Ap p lic a tio n in UPPERC ASE le tte rs using o nly b lac k o r b lue ink.

1. So c ia l Se c urity Num b e r

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. Birth Da te ( MM / DD / YYYY )

3. Are yo u a US C itize n?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ye s

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

M

D

D

Y

Y

Y

Y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

. First Na m e

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. Middle Na m e

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6

. La st Na m e

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14. Wha t is yo ur g e nde r? (O p tio na l)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

F

 

7

. Ma iling Addre ss

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15. Are yo u Hispa nic o r La tino ?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Optio na l, c ho o se o nly o ne )

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No , no t Hispa nic o r La tino

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ye s, Hispa nic o r La tino

 

8

. C ity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16 . Wha t is yo ur ra c e ?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Optio na l, ma rk a ll tha t a pply)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ame ric a n India n o r Ala ska Na tive

 

9

. Sta te

 

10. Zip C o de

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11. Pho ne

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Asia n

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bla c k o r Afric a n Ame ric a n

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. C o untry

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Qdwlyh#Kdzdlldq#ru#Rwkhu#Sdfl￀f#Lvodqghu#

White

13. E- m a il Addre ss:

C U RR E N T V A LI D FLO R I D A E D U C A TO R ’ S C E R TI FI C A TE I N FO R M A TI O N

Sohdvh#vhohfw#|rxu#fxuuhqwo|#ydolg#Iorulgd#Fhuwl￀fdwh#W|sh1#

Pro fe ssio na l

No n- Re ne wa b le Te m p o ra ry

Athle tic C o a c hing

O ne - ye a r Te m p o ra ry

Sohdvh#lqglfdwh#wkh#ydolglw|#shulrg#ri#|rxu#Iorulgd#Fhuwl￀fdwh1#

July 1,

 

 

 

 

to June 3 0,

Vhohfw#khuh#li#|rx#gr#qrw#krog#d#fxuuhqwo|#ydolg#Iorulgd#Hgxfdwruᄋv#Fhuwl￀fdwh1#

C E R TI FI C A TE O R S E RV I C E R E Q U E S TE D : S e e I n s t r u c t i o n s f o r A s s i s t a n c e

Sohdvh#vhohfw#wkh#Fhuwl￀fdwh#Vhuylfh#Uhtxhvwhg1# (Ple a se se le c t o nly o ne se rvic e p e r a p p lic a tio n)

INITIA L

(Fill in sub je c t c o d e b o x b e lo w )

$75 p e r sub je c t se le c te d

 

 

 

A DDNEW

(Fill in sub je c t c o d e b o x b e lo w )

$75 p e r sub je c t se le c te d

 

 

 

PRO C ERT

(Fill in sub je c t c o d e b o x b e lo w )

$75 o nly

 

 

 

NEWPRO

(Fill in sub je c t c o d e b o x b e lo w )

$75 p e r sub je c t se le c te d

 

 

 

C O AC H

(Skip to ne xt se c tio n)

$75 o nly

 

 

 

RETEMP

(Skip to ne xt se c tio n)

$75 o nly

 

 

 

DELETE

(Fill in sub je c t c o d e b o x b e lo w )

$20 p e r sub je c t se le c te d

 

 

 

C O PYC ERT

(Skip to ne xt se c tio n)

$20 o nly

 

 

 

NMC HA NG E

(Skip to ne xt se c tio n)

$20 o nly

 

 

 

Olvw#wkh#vxemhfw+v,#iru#w|sh#ri#Fhuwl￀fdwh#ru#Vhuylfh#Uhtxhvwhg#+Uhihu#wr#Vxemhfw#Duhd2Judgh#Ohyho#Fkduw,

C G -10 APPLIC ATIO N FO RM (2009)

AC ADEMIC TRAINING : PLEASE NO TE ALL C O LLEG ES ATTENDED

Na m e o f C o lle g e (s)/ Bra nc h C a m pus

Sta te

De g re e

G ra dua tio n Da te

Ma jo r

O the r C re dits

Se m Hrs

Atte nda nc e Da te s

NAME IF DIFFERENTWHEN ATTENDING

______________________________________________________________________

 

PRINT NAME (LAST, FIRST, MIDDLE)

 

 

 

 

TE A C H I N G E X P E R I E N C E R E C O R D

(Sub stitute te a c hing e xp e rie nc e is no t a p p ro p ria te .)

 

 

Olvw#Whdfklqj#H{shulhqfh#Vlqfh#Odvw#Iorulgd#Fhuwl￀fdwlrq#Dssolfdwlrq#Vxeplwwhg#

Da te s o f Em plo ym e nt

Na m e o f Em plo ye r

 

(MM/DD/YYYY)

 

 

 

 

 

 

 

 

 

 

Be g in

 

End

Sc ho o l Na m e

C o unty

Sta te

 

 

 

 

 

 

Sub je c t

G ra d e Le ve l

Full- Tim e Pa rt- Tim e

Pub lic o r Priva te Sc ho o l

N O N - FLO R I D A E D U C A TO R C E R TI FI C A TE / LI C E N S E S : Inc lud e A Pho to c o py o f Yo ur C e rtific a te (s) (Fro nt- b a c k) fo r Re vie w

C e rtific a te Typ e

Sta te / Na tio na l

Sub je c t A nd G ra d e Le ve ls

Va lid ity Pe rio d

L E G A L D I S C LO S U R E

Flo rid a La w re q uire s yo u to p ro vid e a YES o r NO a nswe r to the q ue stio ns within the Le g a l Disc lo sure se c tio n o f yo ur a p p lic a tio n, e ve n if p re vio usly sub mitte d .

Wkh#Di￀gdylw#vhfwlrq#pxvw#eh#frpsohwhg#zlwk#|rxu#vljqdwxuh#erwk#wlphv#lw#rffxuv#zlwklq#wkh#irup/#mxvw#ehorz#dqg#dw#wkh#hqg#ri#wkh#Ohjdo#Glvforvxuh#Vxssohphqw/#

fo r yo ur a p p lic a tio n to b e c o mp le te .

A F F I D A V I T

I,__________________________________________________, d o he re b y c e rtify tha t I sub sc rib e to a nd w ill up ho ld the p rinc ip le s inc o rp o ra te d in

PRINT NAME

the C o nstitutio n o f the Unite d Sta te s o f Am e ric a a nd the C o nstitutio n o f the Sta te o f Flo rid a .

I d o he re b y a ffirm tha t a ll info rm a tio n p ro vid e d in my a p p lic a tio n fo r a Flo rid a Ed uc a to r’ s C e rtific a te is true , a c c ura te , a nd c o m p le te .

WA RNING : G IVING FA LSE INFO RM ATIO N IN O RDER TO O BTA IN O R RENEW A FLO RIDA EDUC ATO R’ S C ERTIFIC ATE IS A C RIMINA L O FFENSE UNDER FLO RIDA LAW. A NYO NE G IVING FA LSE INFO RMATIO N O N THIS A FFIDAVIT IS SUBJEC T TO C RIMINA L PRO SEC UTIO N, A S WELL A S DISC IPLINA RY AC TIO N BY THE EDUC ATIO N PRAC TIC ES C O MMISSIO N.

____________________________________________________

_____________________________

APPLICANTS SIGNATURE

DATE

O F F I C I A L U S E O N L Y

E M P LO Y E R D A TE S TA M P

Pa ym e nt Inc lud e d

Am o unt

Me tho d

Num b e r

$ ______________

C K

MO

__________________

C G -10 APPLIC ATIO N FO RM (2009)

C G - 10 APPLIC ATIO N FO R A

FLO RIDA EDUC ATO R’S C ERTIFIC ATE

Flo rida De pa rtm e nt o f Educ a tio n

Bure a u o f Ed uc a to r C e rtific a tio n Ro o m 201, Turling to n Build ing 325 We st G a ine s Stre e t

Ta lla ha sse e , FL 32399-0400

P E RS O N A L I N FO R M A TI O N

Co m p le te in UPPERC ASE le tte rs using o nly b lac k o r b lue ink.

So c ia l Se c urity Num b e r

First Na m e

La st Na m e

LE G A L D I S C LO S U R E #+Iorulgd#Odz#uhtxluhv#|rx#wr#surylgh#d#\HV#ru#QR#uhvsrqvh,#

Afte r a nsw e ring e a c h o f the fo llo w ing q ue stio ns, yo u m ust sig n the A ffid a vit to c o m p le te this se c tio n o f yo ur a p p lic a tio n. Ple a se re fe r to the instruc tio ns in the Le g a l Disc lo sure Sup p le m e nt o n the re ve rse sid e o f this p a g e fo r a d d itio na l info rm a tio n re g a rd ing this se c tio n o f the a p p lic a tio n fo rm .

SEA LED O R EXPUNG ED REC O RDS (Re p o rt O NLY se a le d o r e xp ung e d re c o rd s in this se c tio n)

Iru#hdfk#ri#wkh#iroorzlqj#txhvwlrqv/#li#|rxu#dqvzhu#lv#\HV/#sohdvh#vhohfw#\HV1##Rwkhuzlvh/#vhohfw#QR1

YES

NO

Ha ve yo u e ve r ha d a ny re c o rd se a le d o r e xp ung e d in w hic h yo u w e re c o nvic te d o f a c rim ina l o ffe nse ?

YES

NO

Ha ve yo u e ve r ha d a ny re c o rd se a le d o r e xp ung e d in w hic h yo u w e re fo und g uilty o f a c rim ina l o ffe nse ?

YES

NO

Ha ve yo u e ve r ha d a ny re c o rd se a le d o r e xp ung e d in w hic h yo u ha d a d jud ic a tio n withhe ld o n a c rim ina l o ffe nse ?

YES

NO

Ha ve yo u e ve r ha d a ny re c o rd se a le d o r e xp ung e d in w hic h yo u p le d no lo c o nte nd e re to a c rim ina l o ffe nse ?

YES

NO

Ha ve yo u e ve r ha d a ny re c o rd se a le d o r e xp ung e d in w hic h yo u p le d g uilty to a c rim ina l o ffe nse ?

YES

NO

Ha ve yo u e ve r ha d a ny re c o rd se a le d o r e xp ung e d in w hic h yo u e nte re d into a p re tria l d ive rsio n p ro g ra m o r d e fe rre d

p ro se c utio n p ro g ra m re la te d to a c rim ina l o ffe nse ?

 

 

YES

NO

Do yo u ha ve a p e titio n p e nd ing to se a l o r e xp ung e a ny c rim ina l o ffe nse re c o rd ?

SEA LED o r EXPUNG ED re c o rd s MUST BE REPO RTED p ursua nt to ss. 943.0585 a nd 943.059, Flo rid a Sta tute s. Ho w e ve r, e xiste nc e o f suc h re c o rd s WILL NO T BE DISC LO SED no r m a d e p a rt o f yo ur c e rtific a tio n file w hic h is p ub lic re c o rd .

C RIMINA L O FFENSE REC O RD(S) (Re p o rt a ny re c o rd o the r tha n se a le d o r e xp ung e d in this se c tio n.)

Iru#hdfk#ri#wkh#iroorzlqj#txhvwlrqv/#li#|rxu#dqvzhu#lv#\HV/#sohdvh#vhohfw#\HV1##Rwkhuzlvh/#vhohfw#QR1

YES

NO

Ha ve yo u e ve r b e e n c o nvic te d o f a c rim ina l o ffe nse ?

YES

NO

Ha ve yo u e ve r b e e n fo und g uilty o f a c rim ina l o ffe nse ?

YES

NO

Ha ve yo u e ve r ha d a d jud ic a tio n withhe ld o n a c rim ina l o ffe nse ?

YES

NO

Ha ve yo u e ve r p le d no lo c o nte nd e re to a c rim ina l o ffe nse ?

YES

NO

Ha ve yo u e ve r p le d g uilty to a c rim ina l o ffe nse ?

YES

NO

Ha ve yo u e ve r e nte re d into a p re tria l d ive rsio n p ro g ra m o r d e fe rre d p ro se c utio n p ro g ra m re la te d to a c rim ina l o ffe nse ?

YES

NO

Are the re c urre ntly c ha rg e s p e nd ing a g a inst yo u fo r a ny c rim ina l o ffe nse ?

PRO FESSIO NA L LIC ENSE O R C ERTIFIC ATE SA NC TIO N(S)

Iru#hdfk#ri#wkh#iroorzlqj#txhvwlrqv/#li#|rxu#dqvzhu#lv#\HV/#sohdvh#vhohfw#\HV1##Rwkhuzlvh/#vhohfw#QR1

YESNO

YESNO

YESNO

YESNO

YESNO

YESNO

YESNO

Ha ve yo u e ve r ha d a p ro fe ssio na l lic e nse o r c e rtific a te sa nc tio ne d o r d isc ip line d in this sta te o r a ny o the r sta te ?

Ha ve yo u e ve r b e e n DENIED a p ro fe ssio na l lic e nse o r c e rtific a te in this sta te o r a ny o the r sta te e ve n if the c e rtific a te o r lic e nse wa s la te r issue d w ith c o nd itio ns o r lim ita tio ns?

Ha ve yo u e ve r ha d a p ro fe ssio na l lic e nse o r c e rtific a te susp e nd e d o r re vo ke d in this sta te o r a ny o the r sta te ?

Ha ve yo u e ve r surre nd e re d , re sig ne d , o r re linq uishe d a p ro fe ssio na l lic e nse o r c e rtific a te in this sta te o r a ny o the r sta te d uring o r fo llo w ing a n inve stig a tio n into a lle g a tio ns o f m isc o nd uc t?

Ha ve yo u e ve r ha d a p ro fe ssio na l lic e nse o r p ro fe ssio na l c e rtific a te d isc ip line d in this sta te o r a ny o the r sta te b y re c e iving a le tte r o f re p rim a nd , fine , p ro b a tio n o r a ny o the r re stric tio n o r sp e c ia l c o nd itio ns?

Do yo u ha ve a ny c urre nt inve stig a tive a c tio n p e nd ing in this sta te o r a ny o the r sta te a g a inst a p ro fe ssio na l lic e nse o r c e rtific a te o r a g a inst a n a p p lic a tio n fo r a p ro fe ssio na l lic e nse o r c e rtific a te ?

Do yo u ha ve a ny c urre nt d isc ip lina ry a c tio n p e nd ing in this sta te o r a ny o the r sta te a g a inst a p ro fe ssio na l lic e nse o r c e rtific a te o r a g a inst a n a p p lic a tio n fo r a p ro fe ssio na l lic e nse o r c e rtific a te ?

Li#|rx#dqvzhuhg#\HV#wr#dq|#ri#wkh#suhfhglqj#txhvwlrqv/#|rx#pxvw#surylgh#ghwdlohg#frpsohwh#lqirupdwlrq#iru#hdfk a ffirm a tive re sp o nse in the Le g a l

Disc lo sure Sup p le m e nt o n the re ve rse sid e o f this p a g e a nd sub m it it a lo ng with yo ur a p p lic a tio n fo rm .

CG-10 APPLICATION FORM (2009) LEGAL DISCOLOSURE 1

L E G A L D I S C LO S U R E S U P P L E M E N T

Flo rid a La w re q uire s yo u to p ro vid e a YES o r NO a nsw e r to the q ue stio ns w ithin the Le g a l Disc lo sure se c tio n o f yo ur a p p lic a tio n, e ve n if p re vio usly sub m itte d . If yo u a nsw e re d YES to a ny q ue stio n in the Le g a l Disc lo sure se c tio n o n the a p p lic a tio n fo rm , yo u m ust p ro vid e d e ta ile d c o m p le te info rm a tio n fo r e a c h a ffirm a tive re sp o nse w ithin the c o rre sp o nd ing se c tio n in this Le g a l Disc lo sure Sup p le m e nt.

Yo u a re no t re q uire d to a c kno w le d g e m ino r tra ffic vio la tio ns. The c rim ina l o ffe nse o f Driving Und e r the Influe nc e (DUI) o r Driving While Into xic a te d (DWI) is no t a m ino r tra ffic vio la tio n a nd sho uld b e d isc lo se d o n this fo rm .

Ha ving a c rim ina l histo ry o r a d m inistra tive sa nc tio n a g a inst a p ro fe ssio na l lic e nse d o e s no t a uto m a tic a lly d isq ua lify a p e rso n fro m re c e iving a Flo rid a Ed uc a to r’ s C e rtific a te , b ut suc h inc id e nts w ill p ro m p t a re vie w b y the O ffic e o f Pro fe ssio na l Pra c tic e s Se rvic e s.

Ap e rso n is ine lig ib le fo r e d uc a to r c e rtific a tio n if the p e rso n ha s b e e n frqylfwhg#ri#d#glvtxdoli|lqj#riihqvh#a s liste d in Se c tio n 1012.315 Flo rid a Sta tute s. Ple a se re fe r to www.m y flo rid a te a c he r.c o m fo r m o re info rm a tio n.

First Na m e

M id d le Na m e

La st Na m e

Fo rm e r Na m e

A ny O the r La st Na m e s / A lia se s

S E A L E D O R E X P U N G E D R E C O R D ( S )

C ity Whe re A rre ste d

Sta te

Da te o f A rre st

C ha rg e

Ple a

Disp o sitio n (o utc o m e )

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C R I M I N A L O F F E N S E R E C O R D ( S )

C ity Whe re A rre ste d

Sta te

Da te o f A rre st

C ha rg e

Ple a

Disp o sitio n (o utc o m e )

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

P R O F E S S I O N A L L I C E N S E O R C E R TI F I C A TE S A N C TI O N ( S )

Sta te : ____________________________________

Ye a r: __________________

Lic e nse o r C e rtific a te : __________________________________________________

Issuing Ag e nc y: _____________________________________________________

Sa nc tio n a nd Re a so n: __________________________________________________

 

 

 

Sta te : ____________________________________

Ye a r: __________________

Lic e nse o r C e rtific a te : __________________________________________________

Issuing Ag e nc y: _____________________________________________________

Sa nc tio n a nd Re a so n: __________________________________________________

 

 

 

Sta te : ____________________________________

Ye a r: __________________

Lic e nse o r C e rtific a te : __________________________________________________

Issuing Ag e nc y: _____________________________________________________

Sa nc tio n a nd Re a so n: __________________________________________________

 

 

 

A F F I D A V I T

I d o he re b y a ffirm b y my sig na ture tha t a ll info rm a tio n p ro vid e d in this a p p lic a tio n se c tio n a nd sup p le m e nt is true , a c c ura te , a nd c o m p le te .

WA RNING : G IVING FA LSE INFO RM ATIO N IN O RDER TO O BTA IN O R RENEW A FLO RIDA EDUC ATO R’ S C ERTIFIC ATE IS A C RIMINA L O FFENSE UNDER FLO RIDA LAW. A NYO NE G IVING FA LSE INFO RM ATIO N O N THIS A FFIDAVIT IS SUBJEC T TO C RIMINA L PRO SEC UTIO N, A S WELL A S DISC IPLINA RY AC TIO N BY THE EDUC ATIO N PRAC TIC ES C O MMISSIO N.

____________________________________________________

_____________________________

APPLICANTS SIGNATURE

DATE

CG-10 APPLICATION FORM (2009) LEGAL DISCOLOSURE 2

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Stage no. 1 of submitting form cg 10

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form cg 10 conclusion process outlined (portion 2)

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NMC HA NG E, C G  APPLIC ATIO N FO RM, and o nly of form cg 10

4. Filling in Na m e o f C o lle g e s Bra nc h, Sta te, De g re e, Da te, Ma jo r, Se m Hrs, Atte nda nc e Da te s, G ra dua tio n, NAME IF DIFFERENT WHEN A TTENDING, print name last first middle, T E A C H I N G E X P E R I E N C, Da te s o f Em plo ym e nt, mmddyyyy, Na m e o f Em plo ye r, and Be g in is paramount in the next part - you'll want to take your time and take a close look at each and every blank!

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