Get FL Form CG-10 2017-2024

Official use only CG-10 AppliCAtion for A floridA eduCAtor s CertifiCAte fldoe date stamp pA florida department of education Bureau of Educator Certification Room 201 Turlington Building 325 West Gaines Street Tallahassee FL 32399-0400 pm CK mo CA Vo pn Aff Yes no personAl informAtion Complete entire Application in UPPERCASE letters using only black or blue ink. 1. social security number 2. Birth date mm / dd / YYYY 3. Are you a us Citizen M MD D Y Y Y Y 5. middle name 4. first name 6. last name 14. What is your gender optional M F 7. mailing Address 15. Are you Hispanic or latino optional choose only one no not Hispanic or Latino Yes Hispanic or Latino 8. City 16. What is your race optional mark all that apply 9. state 10. Zip Code American indian or Alaska native Asian Black or African American Native Hawaiian or Other Pacific Islander White 11. phone 12. Country 13. e-mail Address C u r r e n t VA l i d f l o r i dA e d u C At o r s C e r t i f i C At e i n f o r m At i o n Please select your currently valid Florida Certificate Type. professional non-renewable temporary Athletic Coaching one-year temporary Please indicate the validity period of your Florida Certificate. July 1 to June 30 Select here if you do not hold a currently valid Florida Educator s Certificate. CertifiCAte or serViCe reQuested see inst ructions for Assistance Please select the Certificate Service Requested* please select only one service per application initiAl Fill in subject code box below 75 per subject selected AddneW proCert 75 only neWpro CoACH Skip to next section retemp delete CopYCert 20 only nmCHAnGe List the subject s for type of Certificate or Service Requested Refer to Subject Area/Grade Level Chart ACAdemiC trAininG pleAse note All ColleGes Attended name of College s /Branch Campus degree nAme if different WHen AttendinG other Credits Graduation date major sem Hrs Attendance dates print name last first middle t e A C H i n G e X p e r i e n C e r e C o r d substitute teaching experience is not appropriate. List Teaching Experience Since Last Florida Certification Application Submitted dates of employment mm/dd/yyyy Begin name of employer end school name County Grade level subject full-time part-time public or private school n o n - f l o r i d A e d u C A t o r C e r t i f i C A t e / l i C e n s e s include A photocopy of Your Certificate s front-back for review state/ national Certificate type subject And Grade levels Validity period LEGAL DISCLOSURE Florida Law requires you to provide a YES or no answer to the questions within the Legal Disclosure section of your application even if previously submitted* The Affidavit section must be completed with your signature both times it occurs within the form just below and at the end of the Legal Disclosure Supplement for your application to be complete. A f f i dAV i t print name the Constitution of the United States of America and the Constitution of the State of Florida* i do hereby affirm that all information provided in my application for a Florida Educator s Certificate is true accurate and complete. WArninG GiVinG fAlse informAtion in order to oBtAin or reneW A floridA eduCAtor s CertifiCAte is A CriminAl offense under floridA lAW* AnYone GiVinG fAlse informAtion on tHis AffidAVit is suBJeCt to CriminAl proseCution As Well As disCiplinArY ACtion BY tHe eduCAtion prACtiCes Commission* applicant s signature offiCiAl use onlY e m ploYe r dAt e s tA m p payment included Amount method number Mo Complete in UPPERCASE letters using only black or blue ink. l e G A l d i s C l o s u r e Florida Law requires you to provide a YES or NO response After answering each of the following questions you must sign the Affidavit to complete this section of your application* please refer to the instructions in the Legal Disclosure Supplement on the reverse side of this page for additional information regarding this section of the application form* seAled or eXpunGed reCords Report onLY sealed or expunged records in this section For each of the following questions if your answer is YES please select YES* Otherwise select NO. Have you ever had any record sealed or expunged in which you were convicted of a criminal offense prosecution program related to a criminal offense Do you have a petition pending to seal or expunge any criminal offense record Will not Be disClosed nor made part of your certification file which is public record. CriminAl offense reCord s Report any record other than sealed or expunged in this section* Have you ever been convicted of a criminal offense Have you ever pled nolo contendere to a criminal offense Are there currently charges pending against you for any criminal offense license was later issued with conditions or limitations Have you ever surrendered resigned or relinquished a professional license or certificate in this state or any other state during or following an investigation into allegations of misconduct receiving a letter of reprimand fine probation or any other restriction or special conditions Do you have any current investigative action pending in this state or any other state against a professional license or certificate or against an application for a professional license or certificate If you answered YES to any of the preceding questions you must provide detailed complete information for each affirmative response in the legal disclosure supplement on the reverse side of this page and submit it along with your application form* cg -10 application form 2009 legal discolosure 1 submitted* if you answered YES to any question in the Legal Disclosure section on the application form you must provide detailed complete information for each affirmative response within the corresponding section in this Legal Disclosure Supplement. You are not required to acknowledge minor traffic violations. The criminal offense of Driving Under the influence DUi or Driving While intoxicated DWi is not a minor traffic violation and should be disclosed on this form* Having a criminal history or administrative sanction against a professional license does not automatically disqualify a person from receiving a Florida Educator s Certificate but such incidents will prompt a review by the office of professional practices Services. A person is ineligible for educator certification if the person has been convicted of a disqualifying offense as listed in Section 1012.315 Florida Statutes. please refer to www.myfloridateacher.com for more information* former name Any other last names / Aliases City Where Arrested date of Arrest Charge plea disposition outcome State Year License or Certificate issuing Agency Sanction and Reason floridA lAW* AnYone GiVinG fAlse informAtion on tHis AffidAVit is suBJeCt to CriminAl proseCution As Well As disCiplinArY ACtion BY tHe eduCAtion prACtiCes Commission*.