Oregon Tspc C 1 Form PDF Details

In a landscape where the integrity and qualifications of educators are paramount, the Oregon Teacher Standards and Practices Commission (TSPC) plays a crucial role through instruments like the Form C-1, an Application for Educator License or Registration. The form serves as a vital step for educators seeking initial licensing, renewal, registration, or adding endorsements in Oregon, situating itself as a bridge between aspiring and current educators and their professional credentials. It demands from applicants a detailed account of their personal information, educational background, previous licensure, and a self-attestation to a set of professional and ethical standards that the commission upholds. Additionally, it addresses legal concerns by inquiring into applicants' past conduct and any disciplinary actions taken against their professional standing, thereby ensuring the safety and integrity of educational environments. By requiring disclosures such as involvement in prior misconduct investigations or any criminal history, the form not only safeguards the welfare of students but also maintains the profession's dignity. Applicants are also encouraged to demonstrate their commitment to ongoing professional development and to embody the principles that guide ethical behavior within the educational sphere, thus strengthening the foundation for a competent and ethically responsible educator workforce in Oregon.

QuestionAnswer
Form NameOregon Tspc C 1 Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesc 1fillable0412 oregon tspc c 1 form

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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

 

 

 

 

 

 

 

 

Current Mailing Address

Check this box if new address

City, State and Postal Code

()

()

Male

Female

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)

Page 1 of 4

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

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

(TSPC.0001 – 06/01/13)

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Statement of Professionalism

Adopted by the Oregon Teacher Standards and Practices Commission on

April 25, 2013

As educators, we belong to a profession that serves Oregon K-12 students, schools, our communities and the public good. We aspire to a professional standard of conduct that goes beyond merely complying with ethical rules. Professionalism is the courage to care about and act for the benefit of our children, our students, our peers, our careers and the public good.

Because we are committed to professionalism, we will conduct ourselves in a way consistent with the following principles in dealing with our students, our peers, our supervisors, and the public.

Specifically, I will:

Attest to all that I have good moral character.

Put the welfare of children first and will do no physical or emotional harm to a child.

Conduct myself with integrity.

Avoid ALL forms of discrimination against my students and all others.

Commit to academic equity in learning for all of my students.

Commit to educational excellence in all I do.

Respect my colleagues.

Commit to lifelong professional development to improve my skills and the opportunities for my students and the profession.

Resolve disputes with students with compassion, empathy and patience.

Be a role model for my students.

Never violate the student-educator boundaries critical for student achievement and success.

I hereby certify that the information submitted on or relating to this form is true and correct and grant the Commission permission to check civil or criminal records to verify any statement made on this application.

_________________________________________

_____________________________

Signature of Applicant/Educator

Date

_________________________________________

 

Printed Signature

 

(TSPC.0001 – 06/01/13)

Page 3 of 4

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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