• WVDE Form 41

    WVDE Form 41

  • 1. Applicant Information

  • Date of Birth
     - -
  • Gender:*
  • Are You a US Citizen?*
  • Are You Or Your Spouse A U.S. Veteran?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Are you employed by a West Virginia School System?
  • Indicate Race and Ethnicity (Check all that apply)*

  • 2. Disclosure of Background Information

    If you answer yes to any question below, submit a narrative with your application. The narrative should include dates, locations, school systems, and any/all other information that explains the circumstance(s) in detail.
  • Have you ever had adverse action taken against any application, certificate, or license in any state? Adverse action includes but is not limited to the following: letter of warning, reprimand, denial, suspension, revocation, voluntary surrender, or cancellation.*
  • 2) Have you ever been disciplined, reprimanded, suspended, or discharged from any employment because of allegations of misconduct?*
  • 3) Have you ever resigned, entered into a settlement agreement, or otherwise left employment as a result of alleged misconduct?*
  • 4) Is any action now pending against you for alleged misconduct in any school district, court, or before any educator licensing agency?*
  • 5) Have you ever been arrested, charged with, convicted of, or are currently under indictment for a felony?**
  • 6) Have you ever been arrested, charged with, or convicted of a misdemeanor? (For the purpose of this application, minor traffic violations should not be reported.) Charges or convictions for driving while intoxicated (DWI) or driving under the influence of alcohol or other drugs (DUI) must be reported.**

  • 3. Applicant Signature

  • Clear
  • Date
     - -

  • 4. Fingerprinting Information

  • Fingerprinting instructions at https://wvde.us/certification/certification-info/application-forms/first-time-application/

  • Please check one of the following*

  • Commitment for Completing Required College Coursework and/or Professional Development for Specialized Training

  • Clear
  •  
  • Should be Empty: