The Georgia Psc Employer Assurance Form is a document that employers in the state of Georgia are required to complete and submit to the Georgia Public Service Commission (PSC) in order to verify that they are in compliance with state law. The form is used by the PSC to ensure that employers are providing their employees with proper notice of their rights and benefits, as well as complying with other workplace regulations. Completing and submitting the Employer Assurance Form is a simple way for employers to demonstrate their commitment to workplace best practices.
| Question | Answer |
|---|---|
| Form Name | Georgia Psc Employer Assurance Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | EmployerAssuran ce_20120701 gapsc form |
Georgia PSC Employer Assurance Form – Revised June 2021
DO NOT MAIL!
Public School Employer: Must submit electronic form through www.gapsc.org account
All other GA Employers may complete the form for applicant to upload via MyPSC
This form is to be used to verify current employment as a Georgia educator.
1. Applicant Information |
|
|
|
|
|
|
|
Please use dark ink. |
|||||||||||||||||||||||||||||||||||||||
|
Title |
|
|
Last Name |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||
|
Mr. Ms. |
Dr. |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
First Name |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Middle Name |
|||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||
GaPSC Certification ID Number |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Date of Birth (MM/DD/YY) |
|||||||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
/
/
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/YY)
/
3. Transaction Request:
I am requesting the following transaction(s) on behalf of the applicant listed above (check all that apply):
First GA certificate (applicant holds professional
Renewal- A PLP/PLG has been established and the educator is making adequate progress toward meeting the plan/goals?
Yes No Addition of a new field
Conversion or Extension
Upgrade
Montessori certificate Educational Interpreter
|
Field Code: |
|
|
|
(see reverse) |
Other unlisted transaction (please specify):
4. Employer Information:
Name of Superintendent or authorized designee (print/type) |
|
Signature (eSignature not accepted) |
|
||
|
|
|
|
|
|
Title |
|
|
Date |
|
|
|
|
|
|
||
Phone Number |
Email Address |
|
|||
Name of Local Unit of Administration (School System / Agency / Private School / 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.
EMPLOYER ASSURANCE FORM INSTRUCTIONS – Revised June 2021
Note: Please complete all forms legibly in black ink or type.
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. When possible, this form should be submitted electronically through the employer’s account on
www.gapsc.org. 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
CERTIFICATE FIELD CODES
TEACHING FIELDS
Elementary Fields
Birth Through Kindergarten – 870
Elementary Education
SpEd Gen Curriculum/Elementary Education
–708
Middle Grades
Language Arts - 853
Mathematics - 851
Reading - 855
Science - 852
Social Science - 854
Secondary Fields
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 – 619
History – 755
JROTC: Air Force – 643
JROTC: Army – 641
JROTC: Marine Corps – 644
JROTC: Navy – 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 - 656
Cosmetology – 525
Culinary Arts - 669
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/Network Systems - 663
IT/Programming & Software Dev. – 664
IT/Cybersecurity – 676
Manufacturing & Engineering Sciences – 667
Marine Service Technology – 618
Nails – 615
Precision Machine Technology – 668
Law, Public Safety, Corrections & Security – 670
Sheet Metal – 671
Welding Technology – 673
Foreign Languages
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
Deaf Education – 797
Sp Ed General Curriculum – 798
SpEd General Curriculum/Elementary Education
Learning Disabilities – 777 Physical & Health Disabilities – 768 Sp Ed Preschool (ages
Sp Ed Academic Content Concentrations:
|
|||
Language Arts |
930 |
931 |
932 |
Mathematics |
910 |
911 |
912 |
Reading |
950 |
951 |
952 |
Science |
920 |
921 |
922 |
Social Science |
940 |
941 |
942 |
Art – 764
Computer Science – 789
Dance – 820
Drama – 821
Eng. To Speakers of Other Lang. (ESOL) – 885
Gifted
Gifted Concentrations:
Language Arts – 963
Mathematics – 961
Reading – 965
Science – 962
Social Science – 964
Health Education - 760
Health and Physical Education – 761
Music – 767
Reading – 732
SERVICE FIELDS
Audiology – 801
Media Specialist – 813
School Counseling - 709
School Nutrition 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
Educational
Educational Leadership- Tier II
ENDORSEMENTS
Teaching Endorsements: Agriculture Education
Birth Through Five – 871
Career Exploration (PECE) – 749 Career Technical Instruction (CTI) – 810 Coaching Endorsement – 980 Computer Science – 882
Coordinated Career Academic Ed (CCAE)
Dramatic Writing
Gifted
Positive Behavior Intervention and Supports (PBIS) – 189
Reading – 833
Safety & Driver Education – 763 Sp Ed Deaf Education – 874
Sp Ed Physical & Health Disabilities – 875 Sp Ed Preschool (ages
Sp Ed Transition Specialist – 873
Sp Ed Visual Impairment – 876 STEM Education – 186 Urban Education – 891
Service Endorsements:
Student Support Team Coordinator – 888 Teacher Support and Coaching – 712
Leadership Endorsements:
Teacher Leader – 774