ࡱ> qsp v&bjbjdd EhccfP P 8D%N,`bbb+++++++$.d1+@"b+W,9$9$9$j+9$+9$9$V])e*Bb* +,0N,*T1q 1e*1e*TbhJ9$<P5bbb++ ",bbbN,1bbbbbbbbbP [: MAINE DEPARTMENT OF EDUCATION APPLICATION FOR INITIAL CERTIFICATION NAME (First, MI, Last, and optional suffix such as Jr., III)  Social Security Number  Other name(s) under which Your records are filed  DATE Mailing Address  EMAIL Address City or Town State Zip Code Home Phone Sex ____ Male ____ Female Date of Birth / / mo. day yr. RETURN TO: DEPARTMENT OF EDUCATION CERTIFICATION OFFICE 23 STATE HOUSE STATION, AUGUSTA, ME O4333-0023 Certification Request(s) Use separate lines for different codes or levels CODEGRADE LEVELEducational Achievement Degrees only1.Year CompletedSchoolState2.Bachelor3.Master4.C.A.S.5.Doctorate List most recent teacher/educational specialist/administrator experiences: Dates Location (including state) Type of Position Grade Levels _____ to _____ _______________________________________ _____________ __________ _____ to _____ _______________________________________ _____________ __________ THE FOLLOWING QUESTIONS MUST BE ANSWERED AND THE BOX CHECKED: Have you ever had any professional certificate or license revoked or suspended or voluntarily surrendered it?YES_____NO_____Have you ever received a reprimand or other disciplinary action involving any professional certification or license?YES_____NO_____Have you ever been convicted of any misdemeanor or felony offense no matter the age? (this would include OUIs)YES_____NO_____Have you ever been substantiated by any states health and human services department for child abuse, either sexual or physical?YES_____NO_____Are you required to register as a sex offender in any state?YES_____NO_____Do you currently have any outstanding criminal charges or warrants of arrest pending against you in this state or another state or country?YES_____NO_____Have you ever been investigated by an employer for inappropriate conduct or left a position while an investigation was pending, or to stop an investigation from moving forward?YES_____NO_____ If the answer is yes to any of the above, please attach a detailed explanation. I understand that this application contains no misrepresentations or falsehoods. I understand that misrepresentations or falsehoods may be cause for denial or revocation of my educational credential. I understand that I must notify the Commissioner of the Maine Department of Education in writing within 30 days if in the future the answers to any of these questions change.  I authorize the Dept. of Education to charge the applicable fees for this application: M/C ___ VISA ___ EXPIRATION DATE ______ CREDIT CARD NUMBER ____________________________________ I hereby declare or affirm under penalty in the law for unsworn falsification that this application, and any supporting documentation provided in support of this application, contains no willful misrepresentations or falsifications and that the information given by me is true, accurate, and complete to the best of my knowledge and belief, and so far as based on information and belief, I believe the information to be true. I understand that my answers may be verified and that I may be declared ineligible for certification and subject to civil or criminal penalties if there are any misrepresentations. SIGNATURE OF APPLICANT __________________________________________ DATE _____________________ EFC-300-I REV 6/18 Page 2 MAINE DEPARTMENT OF EDUCATION APPICATION FOR INITIAL CERTIFICATION Campus Codes Institution Type Codes 01 Bates 09 Thomas 77 Other Maine Institution PC Public College or University 02 Bowdoin 31 UMA 88 Non-Maine Institution YC Private College or University 03 Colby 32 UMF PX Other Public Institution 04 Husson 33 UMFK YX Other Private Institution 05 Nasson 34 UMM 06 Ricker 35 UMO 07 St. Joseph 36 USM 08 UNE 37 UMPI CERTIFICATE AND SUBJECT ENDORSEMENT CODES AND LEVELS  Administrator Certificates 010 Superintendent of Schools 015 Asst. Superintendent. 030 Administrator of Special Ed. 035 Asst. Administrator of Special Ed. 040 Building Administrator 045 Asst. Building Administrator 057 Teaching Principal 066 Dir. Adult & Community Ed. 068 Asst. Dir. Adult & Community Ed. 078 Curriculum Coordinator/Supervisor Educational Specialist Certificates (K-12) 071 Library/Media Specialist 075 Guidance Counselor 079 Special Ed. Consultant 092 Literacy Specialist 093 School Psychologist (B-12) 094 Vocational Ed. Evaluator (9-12) 215 Athletic Director 293 Speech & Hearing Clinician (B-12) 524 School Nurse Teacher Endorsements 020 General Elementary (K-8) 029 Early Elementary (K-3) 081 Early Childhood (0-5) 100 English/Language Arts (7-12) 200 Social Studies (7-12) 282 Teacher - Disabled Students (0-age 5) 282 Teacher - Disabled Students (K-8) 282 Teacher - Disabled Students (7-12) 286 Teacher - Severe Impaired (K-12) 291 Blind/Visual Impaired (K-12) 292 Deaf/Hearing Impaired (K-12) 300 Mathematics (7-12) 350 Science - Physical (7-12) 395 Science - Life (7-12) 410 Latin (K-12) 420 French (K-12) 430 German (K-12) 440 Spanish (K-12) 450 Russian (K-12) 454 Hebrew (K-12 456 Arabic (K-12) 460 Italian (K-12) 465 Greek (K-12) 470 Chinese (K-12) 480 Japanese (K-12) 488 Native Language (K-12) 510 Physical Education (K-12) 515 Adapted Physical Ed. (K-12) 517 Dance (K-12) 520 Health (K-12) 530 Driver Education (9-12) 614 Music (K-12) 620 Visual Arts (K-12) 625 Theater (K-12) 640 Business Education (K-12) 660 English - Second Language (K-12) 670 Family & Consumer Science (K-12) 680 Computer Technology (K-12) 690 Gifted & Talented (K-12) 700 Industrial Arts/Technology (K-12) Middle Level (5-8) Endorsements 100,200,300,340 (Science) 410,420,430, 440, 450, 460, 470, 480 Adult Education Endorsements (12+) 100,200,300,350,395 Career and Technical Endorsements (9-12) 642 Secretarial 644 Office Clerk General 646 Inst. Home Management Supp. 803 Firefighter/EMT 805 Automotive Mechanics 806 Truck-Bus Driving 807 Vehicle Equip. Operator 808 Automotive Body Repair 809 Diesel Engine Mechanic 810 Carpentry 811 Marine Maintenance 813 Small Engine Repair 816 Brick Block Stone Mason 820 Electrician 823 Computer Info. Services 824 Computer Console Operator 825 Electrical-Electronic 827 Micro-Computer Services  829 Hydraulics 830 Machine Tool Operator/Shop 831 Precision Metal Gen. 833 Metal Fabrication 835 Sheet Metal 836 Weld/Blaze/Solder 837 Precision Metal Other 838 Building Maintenance 840 Graphic Print Comm. 843 Heat/Air Cond. Refrig. 847 Plumbing 848 Barbering 849 Law Enforcement 851 Architectural Drafting 852 Drafting General 853 Blue Print Reading 860 Co-op Indust. Training 861 Commercial Fishing 862 Sailors and Deck Hands 865 Vocational Special Needs 870 Agricultural Prod. 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