Spi Cert 4075s 2015-2026Use a Spi Cert 4075s 2015 template to make your document workflow more streamlined.CHECKLIST Form SPI/CTEcert 4075A-1 Application for adding a specialty area to CTE certificate Fee 1. 00 plus 39. 00 OSPI 40. 00 made payable to OSPI Verification by letter from employer or tax return s for occupational experience Please complete the following and sign the affidavit. OFFICE OF SUPERINTENDENT OF PUBLIC INSTRUCTION Professional Certification Old Capitol Building PO BOX 47200 OLYMPIA WA 98504-7200 360 725-6400 TTY 360 664-3631 Web Site http / /www. k12. wa*us/certification E-Mail cert k12. wa*us Date ESD No* APPLICATION FOR WASHINGTON STATE CAREER AND TECHNICAL EDUCATION ENDORSEMENT Specialty Area Fee 40 Receipt No* NOTE This application is for those who hold a VALID Washington CTE teaching certificate and want to add a specialty area based on completion of verification of occupational experience. CHECKLIST Form SPI/CTEcert 4075A-1 Application for adding a specialty area to CTE certificate Fee 1. 00 plus 39. 00 OSPI 40. 00 made payable to OSPI Verification by letter from employer or tax return s for occupational experience Please complete the following and sign the affidavit. CTE Specialty area s requested Specialty Area Name and VCODE Specialty Area Name and VCODE NAME ADDRESS LAST FIRST MIDDLE CITY/STATE/ZIP DATE OF BIRTH 4. SOCIAL SECURITY NO. OPTIONAL TELEPHONE BUSINESS MAIDEN/FORMER NAME 6. E-MAIL HOME 8. CERTIFICATE NO. Business and Industry Route-Verify three 6 000 hours of paid occupational experience in the subcategory specialty CTE field. One year 2 000 hours must have been completed within the past six years. If all or part of the 2 000 hours is more than 6 years old an additional 300 hours of recent occupational experience occurring in the past two years is required* ATTACH YOUR CHECK TO THIS FORM. APPROVED BY CERTIFICATE TYPE S FORM SPI/VCERT 4075A-1 Rev* 9/15 DATE PROB. G-General S-Specific ISSUE DATE Page 1 of 2 DATE CERTIFICATE MAILED EXPIRATION DATE CLASSIFICATION 4 - New 2 - Renewal TO BE COMPLETED BY APPLICANT Verification of paid occupational experience in the specific career and technical education certificated field is required* Listed employment must be verified by letter from the employer or by tax returns. Self-employment must be verified by submitting a copy of your business license tax return or letters from clients. If teaching is used complete the Teaching Experience form 4075H. Occupation Dates of Employment Total Number of Paid Hours Duties Employer Address City State Zip Code Telephone Number Hours for All Listed Employers AFFIDAVIT I certify or declare under penalty of perjury under the laws of the State of Washington that the foregoing and all information included in this application is true and correct. If the answers to any question on the application or the moral character and personal fitness section on the application change prior to my being granted certification I must immediately notify Career and Technical Education Certification at OSPI. Signature City/State VERIFICATION OF SPECIFIC SAFETY USE THIS FORM ONLY IF YOU HAVE NOT COMPLETED A COLLEGE/UNIVERSITY STATE-APPROVED CAREER AND TECHNICAL EDUCATION TRAINING PROGRAM. We are not affiliated with any brand or entity on this form.How it works
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