CG-10: Florida Educator Certification Application

Under 1. CERTIFICATE OR SERVICE REQUESTED, select a certificate/license type and the corresponding transaction. Only one transaction per application.

For 1. Educator Certification (6001): a. INITIAL (1020), b. UPGRADE (4020), c. REAPPLY (1520), d. ADDTEMP (4010), e. ADDPRO (4015), f. DROPSUBJ (5010), g. COPYCERT (8001), h. NMCHANGE (8002), i. RETEMP (2525), j. EXTNDPRO (6015). For 2. Speech Language Impaired (Bachelor's Only) (6002): a. INITIAL (1020), b. UPGRADE (4020), c. REAPPLY SLA (1520), d. COPYCERT (8001), e. NMCHANGE (8002). For 3. Athletic Coaching (Part-time) (6003): a. INITIAL (1020), b. UPGRADE TO 5 YEAR (4020), c. REAPPLY 5 YR (1520), d. COPYCERT (8001), e. NMCHANGE (8002). For 4. Exchange Teacher (6004): a. INITIAL (1020), b. COPYCERT (8001), c. NMCHANGE (8002).

List the subject codes ONLY for Educator Certification (6001) transactions. Refer to Subject Area/Grade Level Chart.

Under 2. PERSONAL INFORMATION, enter the U. S. Social Security Number*, DOE File Number, Date of Birth (MM/DD/YYYY), U.S. Citizenship Yes or No, First Name (Given Name), Middle Name and Last Name (Family Name).

Failure to provide your SSN to Educator Certification will prevent issuance of your Florida Educator's Certificate.

OPTIONAL: Race (Mark all that apply): American Indian or Alaskan Native, Asian, Black or African American, White, Native Hawaiian or Pacific Islander. Gender: Male or Female. Hispanic or Latino: Yes or No.

Enter the Email Address (For Official Communication from Educator Certification) and the Mailing Address (Street Number and Street Name), City, State, Postal Code and Country.

Under 3. Current Valid Florida Educator's Certificate Information, select here if you do not currently hold a valid Florida Educator's Certificate.

Please indicate the validity period for your Florida Certificate, July 1, to June 30, and select your currently valid Florida Certificate Type: Professional, Temporary or Athletic Coaching.

4. NON-FLORIDA EDUCATOR CERTIFICATES/LICENSES: Must include a photocopy of the front and back of your certificate(s) for review. Enter the Certificate Type, State/National Organization, Certificate Number, Subject and Grade Levels and Validity Period (mm/dd/yyyy to mm/dd/yyyy).

5. ACADEMIC TRAINING: Please list all colleges or universities attended. Enter the Full Name of College(s)/Branch Campus, State, Degree, Graduation Date (MM/DD/YYYY), Major(s), Other Credits Attendance Dates (MM/DD/YYYY) and Last Name While Attending College/University.

6. K-12 TEACHING EXPERIENCE RECORD (Substitute teaching or internship experience is not acceptable.) List teaching experience since last Florida Certification Application submitted.

Enter the Date of Employment (mm/dd/yyyy) Begin and End, Name of Employer, School Name and Supervisor, County/City, State, Subject(s) and Grade Level(s), Full-Time/Part-Time and Public or Private School.

7. COLLEGE TEACHING EXPERIENCE RECORD (A letter on official letterhead from the dean or registrar verifying your experience is required.)

Enter the Full Name of Institution, Full-Time/Part-time, Course Prefix and Number, Start Date of Employment (mm/dd/yyyy), End Date of Employment (mm/dd/yyyy) and Semester Hours.

Under 8. APPLICANT SIGNATURE, fill in I, ____, agree to pay $ for the non-refundable application processing fee; sign on the Applicant's Signature line.

9. PAYMENT INFORMATION (Please make fees payable to FLDOE Educator Certification): enter the Amount, mark the Method Check, Cash, Money Order or Voucher and enter the Payment Number.

10. APPLICATION AFFIDAVIT: I, Print Name, do hereby certify that I subscribe to and will uphold the principles incorporated in the Constitution of the United States of America and the Constitution of the State of Florida. I do hereby affirm that all information provided in my application for a Florida Educator's Certificate is true, accurate, and complete.

Giving false information in order to obtain or renew a Florida Educator's Certificate is a criminal offense under Florida law. Anyone giving false information on this affidavit is subject to criminal prosecution, as well as disciplinary action by the Education Practices Commission. Applicant's Signature, Date.

Under PERSONAL INFORMATION, enter the U.S. Social Security Number, DOE File Number, Last Name and First Name.

11. LEGAL DISCLOSURE: Florida Law requires you to provide a YES or NO answer to the questions within the Legal Disclosure section of your application, even if previously submitted.

You are not required to acknowledge minor traffic violations. The criminal offense of Driving Under the Influence (DUI) or Driving While Intoxicated (DWI) is not a minor traffic violation and should be disclosed on this form.

Having a criminal history or administrative sanction against a professional license does not automatically disqualify a person from receiving a Florida Educator's Certificate, but such incidents will prompt a review by the Office of Professional Practices Services. A person is ineligible for educator certification if the person has been convicted of a disqualifying offense as listed in Section 1012.315 Florida Statutes. Please refer to www.myfloridateacher.com for more information.

SEALED OR EXPUNGED RECORDS (Report ONLY sealed or expunged records in this section.) For each of the following questions, if your answer is YES, please select YES. Otherwise, select NO. Have you ever had any record sealed or expunged in which you were convicted of a criminal offense, found guilty of a criminal offense or had adjudication withheld on a criminal offense? Have you ever had any record sealed or expunged in which you pled nolo contendere to a criminal offense, pled guilty to a criminal offense or entered into a pretrial diversion program or deferred prosecution program related to a criminal offense? Do you have a petition pending to seal or expunge any criminal offense record?

SEALED OR EXPUNGED records MUST BE REPORTED pursuant to § 943.0585 and 943.059, Florida Statutes. However, existence of such records will not be disclosed nor made part of your certification file which is public record.

CRIMINAL OFFENSE RECORD(S) (Report any record other than sealed or expunged in this section.) For each of the following questions, if your answer is YES, please select YES. Otherwise, select NO. Have you ever been convicted of, been found guilty of, had adjudication withheld on, pled nolo contendere to or pled guilty to a criminal offense, or entered into a pretrial diversion program or deferred prosecution program related to a criminal offense? Are there currently charges pending against you for any criminal offense?

PROFESSIONAL LICENSE OR CERTIFICATE SANCTION(S): For each of the following questions, if your answer is YES, please select YES. Otherwise, select NO. Have you ever had a professional license or certificate sanctioned or disciplined in this state or any other state? Have you ever been DENIED a professional license or certificate in this state or any other state even if the certificate or license was later issued with conditions or limitations? Have you ever had a professional license or certificate suspended or revoked in this state or any other state? Have you ever surrendered, resigned, or relinquished a professional license or certificate in this state or any other state during or following an investigation into allegations of misconduct? Have you ever had a professional license or professional certificate disciplined in this state or any other state by receiving a letter of reprimand, fine, probation, or any other restriction or special condition? Do you have any current investigative action pending, or any current disciplinary action pending, in this state or any other state against a professional license or certificate or against an application for a professional license or certificate?

If you answered YES to any of the preceding questions, you must complete all information within the Legal Disclosure Supplement on the next page. Please provide detailed information for each affirmative response and submit this form to complete your application.

12. LEGAL DISCLOSURE SUPPLEMENT: enter the First Name, Middle Name, Last Name, Former Name and Any Other Last Names/Aliases.

Under SEALED OR EXPUNGED RECORD(S) and under CRIMINAL OFFENSE RECORD(S), enter the City, State, Date mm/dd/yyyy, Charge, Plea and Disposition (outcome).

Under PROFESSIONAL LICENSE OR CERTIFICATE SANCTION(S), enter the State, Year, License or Certificate, Issuing Agency and Sanction and Reason.

LEGAL DISCLOSURE AFFIDAVIT: I, Print Name, affirm that all information provided in this Legal Disclosure section and Supplement to my application for a Florida Educator's certificate is true, accurate, and complete. Applicant's Signature and Date.