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New Jersey State Department of Education -- Office of Certification and Induction NON-CITIZEN OATH OF ALLEGIANCE IMPORTANT This form is to be completed by only those individuals who are NOT U.S. citizens. Applicant s Signature in ink Sworn and subscribed to before me this day of 20 Notary Seal Notary Signature Once completed mail the form to Office of Certification and Induction P. O. Box 500 Trenton New Jersey 08625-0500 Attention Non-Citizen Oath of Allegiance Revised 05-20-14. A. Please print your name as it appears on any documentation that you are required to submit. Last Name First Name Middle Name/Initial Street Address City State Zip Month Day Year Date Of Birth Area Code E-mail Address Phone Number Endorsement Information* Please enter below the code and print the name of the each endorsement for which you are applying. Endorsement Code Endorsement Name Social Security Number B. Oath of Allegiance choose one of the options below. To be subscribed to by non-citizens pursuant to N*J*S*A. 18A 26-9. Option I I do solemnly swear or affirm that during the period of my employment I will support the Constitution of the United States and the Constitution of the State of New Jersey so help me God. C. Certification Failure to complete these items will result in rejection of the candidate s application for certification* Circle whichever applies Have you ever had a certificate revoked or suspended in this or any state If yes enclose a statement indicating the action taken and provide the pertinent details. Yes No Have you ever been convicted of a criminal offense in this or any other state or any jurisdiction outside of the United States If yes enclose a statement indicating the municipality where this occurred and provide the pertinent details. D. Verification of Accuracy I certify that all statements and information provided herein are true and accurate. Applicant s Signature in ink Sworn and subscribed to before me this day of 20 Notary Seal Notary Signature Once completed mail the form to Office of Certification and Induction P. O. Box 500 Trenton New Jersey 08625-0500 Attention Non-Citizen Oath of Allegiance Revised 05-20-14. A. Please print your name as it appears on any documentation that you are required to submit. Last Name First Name Middle Name/Initial Street Address City State Zip Month Day Year Date Of Birth Area Code E-mail Address Phone Number Endorsement Information* Please enter below the code and print the name of the each endorsement for which you are applying. Endorsement Code Endorsement Name Social Security Number B. Oath of Allegiance choose one of the options below. Endorsement Code Endorsement Name Social Security Number B. Oath of Allegiance choose one of the options below. To be subscribed to by non-citizens pursuant to N*J*S*A. 18A 26-9. Option I I do solemnly swear or affirm that during the period of my employment I will support the Constitution of the United States and the Constitution of the State of New Jersey so help me God.

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