Wv Form 39 PDF Details

The WV 39 form, emanating from the Office of Professional Preparation, plays a crucial role in the vetting process for individuals seeking permits or authorizations within the educational sector of West Virginia. This comprehensive form serves multiple functions, from ensuring that applicants meet the necessary employment qualifications to confirming their eligibility for specific roles, such as coaching, athletic training, and limited football training positions. Applicants are required to disclose background information, which includes any past adverse actions taken against their professional licenses or any criminal history, to maintain transparency and uphold the integrity of the educational environment. Furthermore, the form necessitates a detailed narrative from the applicant should there be any affirmative responses to questions regarding past disciplinary actions or criminal charges, ensuring that all relevant details are thoroughly examined. Sections dedicated to fingerprinting information and superintendent recommendations highlight the stringent checks and balances in place, aiming to safeguard the welfare of students. The inclusion of specific documentation, such as proof of educational attainment and professional certifications, underscores the meticulous approach adopted by the West Virginia Board of Education in credentialing educators and support staff. This detailed scrutiny reflects the commitment of the state to provide a safe and conducive learning environment for all students.

QuestionAnswer
Form NameWv Form 39
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameswv authorization coaches football, wvssac form 39, wv temprary trainers football, form limted football template

Form Preview Example

 

 

 

 

 

 

Office of Professional Preparation

Applicant Information Page for Permits/Authorizations that Require Employment

 

 

 

 

 

Check if applicable:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Self or spouse on Active Duty

 

 

 

 

 

 

 

 

 

 

 

Building 6, Room 722

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Received by County Board of Education:

____________________________

 

 

 

Self or spouse within 6 months after

 

 

 

 

 

 

 

 

 

1900 Kanawha Boulevard East

 

 

 

 

 

 

 

 

 

 

 

 

 

Charleston, WV 25305

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Active Duty

 

 

 

 

 

 

 

 

 

 

 

304-558-7010 7/01/14

 

 

Date Received by Institution of Higher Education: ___

_________________

 

 

 

See our website for additional documents required.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part 1 -Applicant Information

 

 

 

 

Part 2-Disclosure of Background Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_________________

 

__________________

 

_____________

_________________

 

_____________________

If you answer yes to any question

 

 

 

 

 

 

 

 

 

 

Documentation Attached

 

 

 

 

 

below, SUBMIT a narrative with

 

 

 

 

Social Security Number

Birth Date (MM-DD-YYYY)

Gender (M or F)

US Citizen ( Y or N)

US Veteran or Spouse of veteran

your

 

application.

The narrative

YES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

( Y or N) If Yes complete box -top right

should include dates, locations, school

NO

 

 

____________________________________

______________________________ _____ ________________________________________

systems, and all/any other information

 

 

Last Name

 

 

 

First Name

 

 

 

 

 

 

 

MI

Previous Last Name (Maiden)

 

that

explains the

circumstance(s) in

 

 

(If your name has changed since your last application, proof of name change must be attached e.g. photocopy of marriage certificate, etc.)

detail.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_______________________________________________________ _____________________________________ _______ ______________

1) Have you ever had adverse action

 

 

 

 

 

taken

against

any

application,

 

 

 

 

 

Street Address

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

certificate, or license in any state?

 

 

 

 

 

__________________________________ ___________________________________ ____________________________________________

Adverse

action

includes

but is

not

 

 

 

 

 

limited

to

the

following: letter of

 

 

 

 

 

Primary Phone

 

Secondary Phone

 

 

 

 

 

 

 

E-Mail

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

warning, reprimand, denial, suspen-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List the institutions from which a degree has been earned

 

 

 

Are you currently employed by

 

Do you currently hold a License to

sion,

revocation,

voluntary surrender

 

 

 

 

 

 

 

a West Virginia School System?

 

work in the public schools of West

or cancellation.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

Virginia?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

College/University

 

Degree

 

Date

 

 

 

 

 

2) Have you ever been disciplined,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If YES, please indicate the

 

Do you currently hold a License to

reprimanded,

suspended,

or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

school system:

 

 

work in the public schools of an-

discharged

from

any

 

employment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

other state?

 

because of allegations of misconduct?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3) Have you ever resigned, entered

 

 

 

 

 

 

 

 

 

 

 

Part 3—Applicant Signature

 

 

 

 

 

 

 

into a settlement agreement, or oth-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

erwise left employment as a result of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

alleged misconduct?

 

 

 

 

 

 

 

 

I swear or affirm under the penalty of false swearing that all information provided in or with this application is true, correct, and complete to the best of my knowledge. I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4) Is any action now pending against

 

 

 

 

 

understand that any false statements, misrepresentations, or omissions of fact in or with this application are grounds for denial, suspension, or revocation of the license(s)

 

 

 

 

 

that I am seeking or currently hold.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

you for alleged misconduct in any

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

school district, court, or before any

 

 

 

 

 

___________________________________________

 

 

__

 

 

 

 

_________________________

 

 

 

educator licensing agency?

 

 

 

 

 

 

Signature of Applicant

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5) Have you ever been arrested,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A non-refundable fee is required for each application. You may pay

 

 

 

 

 

Supporting documentation attached:

 

charged

with,

convicted

of, or

are

 

 

 

 

 

online at https://wveis.k12.wv.us/certpayment/.

Applications attached:

 

 

 

 

 

(non-fee required Forms, e.g. Forms 4B, 7, V10, V16)

currently under indictment for a felo-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

______________ ______________

______________

 

 

 

______________

______________ ______________

ny? *

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form #

Form #

 

 

Form #

 

 

 

 

 

 

 

Form #

 

Form #

 

Form #

 

6) Have you ever been arrested,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

charged with or convicted of a

mis-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part 4—Fingerprinting Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

demeanor? (For the purpose of this

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

application,

minor traffic violations

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First-time applicants are required to have fingerprints processed by L-1 Solutions (L1enrollment.com).

 

should not be reported) Charges or

 

 

 

 

 

I have previously received Certification in WV and understand that I do not need to re-submit my fingerprints.

convictions for driving while intoxicat-

 

 

 

 

 

ed (DWI) or driving under the influ-

 

 

 

 

 

I have never held WV Certification and have recently submitted my fingerprints to L1 Solutions on ______/______/_________

ence of alcohol or other drugs (DUI)

 

 

 

 

 

 

 

 

 

(L1 Transaction #________________________)

 

 

 

 

 

 

must be reported. *

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part 5 - Superintendent Recommendation (Required for Permit/Authorization Application)

* For a YES response to items 5 & 6, the follow-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I certify that I have reviewed and can attest to the accuracy and truthfulness of the information provided in this application.

When necessary, I have

ing must be included for all charges, including

 

 

included documentation verifying this information. I have reviewed the disclosure of background information, and, to the best of my knowledge, the

those that have been dismissed or expunged: 1)

 

 

applicant is of good moral character and is physically, mentally, and emotionally qualified to perform the duties of a teacher. I recommend that s/he be

Judgment Order; OR 2) Final Order; OR 3) Mag-

 

 

granted certification.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

istrate Court Documentation; AND 4) all other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

____________________________________

 

 

_________

_____________________________

________________________________

relevant court documentation.

 

 

 

 

 

Signature of Superintendent

 

 

 

 

 

 

 

County

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form 39-Temporary Authorization for Coaches, Athletic Trainers, & Limited Football Trainers

Social Security Number: ________________________

Last Name: ____________________________ First Name: _________________________ MI: ____

REV 20130718

Coaching

Limited Football Trainer

Athletic Trainer

 

 

 

Original Coaching Authorization

Proof of High School Diploma or Equivalent

Proof of Completion of WVSSAC Coaching Principles

Proof of Completion of WVSSAC First Aid Course

Proof of Completion of WVSSAC Association Course

**Must also complete 1, 2, and 3 below

Renewal of Coaching Authorization

1-____________________________________________

Job Posting Date

2-_____________________________________________

Employment Begin Date

3-_____________________________________________

School Year

WVBE Policy 5202 §126CSR136 11.8.1.I requires the applicant for this Authorization to possess the minimum of high school diploma or GED, be employed under contract with a board of education to serve as a coach, attend appropriate WVSSAC-sponsored professional development and receive the recommendation of the county superintendent verifying that no currently employed, professionally licensed educator applied for the position.

Original Limited Football Trainer

Authorization

I have enclosed the following :

Copy of Current Health Care Provider License (M.D., R.N., P.T., E.M.T, etc.)

Affirmation of in-person attendance at the WVSSAC Athletic Trainer Rules Clinic

Date Attended: ____________________

Proof of High School Diploma or Equivalent

**Must also complete 1 and 2 below

Renewal of Limited Football

Trainer Authorization

I have enclosed the following :

Copy of Current Health Care Provider License (M.D., R.N., P.T., E.M.T, etc.)

Date Attended: _____________________

1-_____________________________________________

Employment Begin Date

2- ————————————————————————————

School Year

WVBE Policy 5202 §126CSR136 20.3 allows this authorization to be issued in the event the county board of education cannot obtain Athletic Trainers as described in §20.3.1.

Original Athletic Trainer Authorization

Proof of VALID NATABOC certification enclosed

Proof of registration with WV Board of

Physical Therapy

**Must also complete 1 and 2 below

Renewal of Athletic Trainer Authorization

Proof of VALID NATABOC certification enclosed

Proof of registration with WV Board of

Physical Therapy

1-_____________________________________________

Employment Begin Date

2-_____________________________________________

School Year

WVBE Policy 5202 §126CSR136 20.2 requires the applicant for this Authorization to hold a minimum of a high school diploma or GED and be certified through the National Athletic Trainers Association Board of Certification (NATABOC) and who has registered with the West Virginia Board of Physical Therapy.

Applicant Information Page must be attached.

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2. Your next step would be to fill in these particular blank fields: I swear or affirm under the, Date, A nonrefundable fee is required, Form Form Form, Supporting documentation attached, nonfee required Forms eg Forms B, Form Form Form, Part Fingerprinting Information, Firsttime applicants are required, I have previously received, I have never held WV, L Transaction, Part Superintendent, I certify that I have reviewed and, and Signature of Superintendent.

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3. The following step is about REV, Coaching, Original Coaching Authorization, Proof of High School Diploma or, Proof of Completion of WVSSAC, Proof of Completion of WVSSAC, Proof of Completion of WVSSAC, Must also complete and below, Renewal of Coaching Authorization, Must also complete and below, I have enclosed the following, Form Temporary Authorization for, Social Security Number Last Name, Limited Football Trainer, and Athletic Trainer - fill in each of these blank fields.

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