A
PPLICATION TO
E
I
A
C
XTEND AN
NTERIM
DMINISTRATIVE
ERTIFICATE
– C
A
D
E
U
RIZONA
EPARTMENT OF
DUCATION
ERTIFICATION
NIT
S
3: C
H
ECTION
RIMINAL
ISTORY
- Answer EVERY question, sign and date. Attach Explanation of Incident, if required.
If “YES” is indicated for any of the following questions, you must attach an Explanation of
ATTENTION:
ATTENTION:
Incident form to your application before it can be processed. You may download the form at:
1. YES__ NO___ Have you ever had any professional certificate or license,
2. YES__ NO___ Have you ever received a reprimand or other disciplinary action
revoked or suspended?
involving any professional certification or license?
3. YES__ NO___ Have you ever been convicted of any felony offense?
4. YES__ NO___ Have you ever been arrested for any offense for which you
were fingerprinted?
5. (Answer every
5. (Answer every
Have you ever been arrested for any of the following
(continued) Have you ever been arrested for any of the
question.)
offenses in this state or similar offenses in another
question.)
following offenses in this state or similar offenses in
jurisdiction?
another jurisdiction?
YES__ NO___ Second-degree murder
YES__ NO___ Continuous sexual abuse of a child
YES__ NO___ Aggravated assault resulting in serious physical injury or
YES__ NO___ Attempted first-degree murder
YES__ NO___ Any other dangerous crime against children as defined in
involving the discharge, use or threatening exhibition of
a deadly weapon or dangerous instrument against a
section A.R.S. § 13-604.01
YES__ NO___ Any of the above listed offenses if committed as a
minor under fifteen years of age
YES__ NO___ Sexual assault
reparatory offense as described in A.R.S. 13-1001
YES__ NO___ Molestation of a child
YES__ NO___ Any offense causing you to register as a sex offender
YES__ NO___ Sexual conduct with a minor
YES__ NO___ First-degree murder
YES__ NO___ Commercial sexual exploitation of a minor
YES__ NO___ Armed Robbery
YES__ NO___ Sexual exploitation of a minor
YES__ NO___ Incest
YES__ NO___ Child abuse
YES__ NO___ Exploitation of minors involving drug offenses
YES__ NO___ Kidnapping
YES__ NO___ Sexual abuse of a vulnerable adult
YES__ NO___ Sexual abuse of a minor
YES__ NO___ Sexual exploitation of a vulnerable adult
YES__ NO___ Taking a child for the purpose of prostitution as
YES__ NO___ Commercial sexual exploitation of a vulnerable adult
YES__ NO___ Abuse of a vulnerable adult
prescribed in section A.R.S. § 13-3206
YES__ NO___ Child prostitution as prescribed in section ARS 13-3212
YES__ NO___ Molestation of a vulnerable adult
YES__ NO___ Involving or using minors in drug offenses
YES__ NO___ Neglect of a vulnerable adult
I understand that pursuant to ARS § 15-534, any person who makes a false statement, representation or certification in any application for certification is
guilty of a misdemeanor offense. I swear or affirm that the foregoing information completed by me, or submitted by me for certification purposes is, to the best
of my knowledge, true and correct. Furthermore, should any part or all of the information herein provided prove to be false, I recognize that it shall be just
cause for revocation, suspension, or other disciplinary action against any certificate issued to me by the Arizona Department of Education.
____________________________________________ _____________
Applicant’s Signature
Date
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EQUIREMENTS MAY BE SUBJECT TO CHANGE AND ARE FULLY REFERENCED IN THE
RIZONA
EVISED
TATUTES AND
DMINISTRATIVE
ODE
Version 3.0 (Rev. 2/18/2014)
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