Oregon Tspc C 1 Form – Fill Out and Use This PDF

Teacher Standards and Practices Commission

250 Division St NE
Salem, OR 97301	Email: contact.tspc@state.or.us
Phone (503) 378-3586; Fax (503) 378-4448	Web Site: www.oregon.gov/tspc

Application for Educator License or Registration – Form C-1

Before completing this form please read the instructions carefully. Once complete, sign the application, attesting to the accuracy of information provided. Providing false information on your application is grounds for the Commission to deny your application or revoke your license or registration.

Please write legibly and use black or blue ink. Please be sure to provide your full legal name.

LAST NAME	FIRST NAME	MIDDLE NAME	PREVIOUS

Home/Cell phone number Work phone number		Date of Birth	Gender

Social Security Number

E-mail Address

As part of your application for an initial or renewed license or registration, you are required to provide your Social Security Number (SSN) for purposes of child support enforcement (ORS 25.785 and 42 USC § 666(a)(13)) and state income tax collection (ORS 305.385 and 42 USC § 405(c)(2)(C)(i)).

The Commission may also disclose your SSN to the interstate clearinghouse for educators if your Oregon license or registration is subject to discipline for unprofessional conduct (ORS 342.143 and 342.175 to 190).

Ethnic and Race Status: (Optional - for statistical purposes only)

1.	Which race or ethnicity best describes you? (You may check more than one)
	American Indian or Alaska Native			Asian	Black or African American
	Hispanic or Latino or other Spanish Origin				Native Hawaiian or Other Pacific Islander
	Multi-ethnic	White	Other
2.	If you checked above that you are an American Indian, please check here if you are a
	member of one of the nine recognized tribes in Oregon.

Previous Educational Licenses, Registrations, and Certifications: (Required information)

1.Have you held any type of Oregon educational license previously? Yes No

2.Have you held any license valid for full-time educational work (to include substitute teaching) in another state? Yes No

3.If yes to #2, in which other state or states are/were you licensed? ______________________

4.When did you receive your first unrestricted license in another state? _________________

5.Under what name(s) (in Oregon or another state) were you previously licensed? __________________

(TSPC.0001 – 06/01/13)

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PURPOSE FOR FILLING OUT THIS APPLICATION

Apply for new type of license (administrator, counselor, etc.): _______________________________

Add endorsement(s): _____________________________

Reinstate an expired license: _________________________________

Renew an existing license: _______________________________

Charter School Registration:	First time application or		Renewal
	Teacher or	Administrator
Other: ______________________________

ACADEMIC DEGREES & EDUCATOR PROGRAMS COMPLETED

List all institutions from which you have earned a degree, unless already on file with TSPC. Also list all teacher, counselor, psychologist, or administrator programs you have completed, regardless of any connection to a degree. If you have not yet completed a degree or educator licensure program, please state “NONE.”

1.______________________________ ___________________________ ___________________________ ________________________

College or University

City & State

Major/Program

Degree earned (BS, MAT, etc.)

2.______________________________ ___________________________ ___________________________ ________________________

College or University

City & State

Major/Program

Degree earned (BS, MAT, etc.)

3.______________________________ ___________________________ ___________________________ ________________________

College or University

City & State

Major/Program

Degree earned (BS, MAT, etc.)

4.______________________________ ___________________________ ___________________________ ________________________

College or University

City & State

Major/Program

Degree earned (BS, MAT, etc.)

5.______________________________ ___________________________ ___________________________ ________________________

College or University

City & State

Major/Program

Degree earned (BS, MAT, etc.)

Please Note: For some license applications, you will be required to submit official transcripts to verify coursework. Please see renewal and application instructions for individual licenses to determine what you need to submit.

EXPERIENCE AS PROFESSIONAL EDUCATOR

List all of your employment experience in the last five years as a teacher, school counselor, psychologist, social worker or administrator to TSPC. If none, state “NONE”. If you worked as a substitute (full or restricted), please indicate.

Dates	Name of School	City & State	Grade	Contracted		Substitute
From:	To:		Level(s)	½ time or more?		experience?
				Yes	No	Yes	No

(TSPC.0001 – 06/01/13)

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CHARACTER QUESTIONS

Please carefully read the “Instructions for Answering Character Questions” before answering. You must answer either “yes” or “no” to each of the following questions; any other response will result in your application being considered incomplete. All "yes" answers must be fully explained in writing on a separate piece of paper and the explanations must be signed and dated by you. You must also include certified true copies of all legal documents, including court records.

1.	Have you ever left any educational or school-related employment, voluntarily or involuntarily, while
	the subject of an inquiry, review or investigation of alleged misconduct? Have you ever left	1.
	educational or school-related employment when you had reason to believe an investigation for
	misconduct was underway or imminent?
2.	Are you currently the subject of an inquiry, review or investigation for alleged misconduct or
	alleged violation of professional standards of conduct by either an employer or a licensure	2.
	agency?
3.	Have you ever been placed on leave by your employer for any alleged misconduct?	3.
4.	Have you ever had any adverse action taken on a professional certificate, license or charter
	school registration? Have you ever been placed on probationary status for alleged misconduct	4.
	while holding a professional license, certificate, registration, or credential?
5.	Have you ever been denied any professional license for which you applied or granted a
	professional license on a conditional or probationary basis for any alleged misconduct?	5.
6.	Have you ever surrendered a professional license of any kind before its expiration?	6.
7.	Have you ever been disciplined by any public agency responsible for licensure of any kind,	7.
	including but not limited to educational licensure?
8.	Have you ever been convicted or been granted a diversion or conditional discharge by any court
	for any: (a) Felony; or (b) Misdemeanor; or (c) Major traffic violation including but not limited to:
	driving under the influence of intoxicants or drugs; reckless driving; fleeing from or attempting to	8.
	elude a police officer; driving while your license was suspended, revoked or used in violation of
	any license restriction; or failure to perform the duties of a driver or witness at an accident?
9.	Have you ever been arrested or cited for any offense listed in section (8) above which is still
	pending in the courts? This includes any diversion, conditional discharge or postponed	9.
	adjudication that has not been dismissed by the courts at the time this application is signed.
10. Have you ever had any civil judgment or other court order, including but not limited to a restraining
	order, entered against you resulting from allegations of abuse, assault, battery, harassment,	10.
	intimidation, neglect, stalking, or other threatening behavior toward other persons?

Check here if you provided an explanation for any “yes” answer with a prior application. Please know that any new incident that occurred since your last application requires that you answer “yes” and include a full written explanation, along with applicable court documents.

Your Signature and the Date: Under penalty of false swearing, I declare that the information in this application is true, correct, and complete. Providing false information is grounds for the Commission to deny my application or revoke my license or registration. I also grant the Commission permission to check civil or criminal records to verify any statement made on this application.

Signature of the Applicant

Date*

*This application must be signed and dated within 60 days prior to the date the application is received by TSPC.

YOU MUST PRINT AND MAIL THIS FORM DIRECTLY TO: TSPC

250 Division St. NE

Salem, Oregon 97301

(TSPC.0001 – 06/01/13)

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