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SECTION III. CHARACTER AND FITNESS

(This form must be completed with each certification application and submitted to the Education Professional Standards Board, Division of Certification, 100 Airport Road, 3rd Floor, Frankfort, KY 40601, (502) 564-4606, (888) 598-7667, or www.Kyepsb.net)

Name: ___ Social Security Number: ___

Address: ___

(City) (State) (Zip Code)

(Street)

Telephone Number: ( )

Answer each question by circling "yes" or "no." If you answer "yes" to any question, you must submit a full explanation using a separate sheet of paper.

If you have ever held, or currently hold a professional certificate, license, credential, or other document issued to you by any jurisdiction (other than Kentucky) within the United States or abroad, enclose a copy of the certificate(s) or provide the following:

State or Jurisdiction ___ Certificate Number ___

Type ___ Issue Date ___ Expiration Date ___

1. Have you ever had a professional certificate, license, credential, or any document issued to you for practice denied, suspended, revoked, or voluntarily surrendered?
2. Are you currently being reviewed or investigated for purposes of such action as stated in #1 or is such action pending?
3. Have you ever been dismissed, resigned, released, or asked to resign/retire or discharged from a professional position or military service for immorality, incompetence, willful neglect of duty, misconduct, or presenting false information toward obtaining the position?
4. Is any such action as stated in #3 pending? Yes No
5. Have you ever been convicted of a felony or misdemeanor (other than a moving traffic violation), been found guilty, or entered a plea of nolo contendere (no contest), even if adjudication was withheld, in Kentucky or any other state?
6. If you indicated "yes" to any items, #1 through #6, has that action been reviewed. Yes No by the Education Professional Standards Board?

(Date of Review)

I affirm and declare that all information given by me on this form is true, and correct, and complete to the best of my knowledge. I understand that any misrepresentation of facts, by omission or addition, may result in the denial or revocation of my teaching certificate. Further, I understand that KRS 161.120 provides that a teaching certificate may be revoked at any time upon determination that false information was presented toward obtaining a teaching certificate.

I declare that I understand the standard for personal and professional conduct expected of a professional educator in Kentucky. I further certify that I have read and examined the CODE OF ETHICS (page 4) applicable to school personnel, understand its provisions, and agree to abide by its terms during the course of my career as a professional educator.

SIGNATURE___ DATE ___

DATE

Revised Spring 2018