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"Teacher certification (date, field", "field_kind": "text", "label": "Teacher certification (date, field", "pdf_field_name": "Teacher certification date field", "pdf_field_type": "Text", "reading_order": 18 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 434.76, "t": 439.68, "r": 540.24, "b": 420.12 }, "text": "Student teaching (dates, district, school, classroom setting, Cooperating Teacher [1]", "field_kind": "text", "label": "Student teaching (dates, district, school, classroom setting, Cooperating Teacher [1]", "pdf_field_name": "Student teaching dates district school classroom setting Cooperating Teacher 1", "pdf_field_type": "Text", "reading_order": 19 }, { "page": 1, "type": "TEXT", "location": { "l": 69.84, "t": 431.52, "r": 433.44, "b": 417.12 }, "text": "Student teaching (dates, district, school, classroom setting, Cooperating Teacher):", "reading_order": 20 }, { "page": 1, "type": "TEXT", "location": { "l": 70.8, "t": 411.36, "r": 541.68, "b": 396.96 }, "text": 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"reading_order": 37 }, { "page": 2, "type": "TEXT", "location": { "l": 358.08, "t": 340.8, "r": 541.44, "b": 326.4 }, "text": "Telephone: ___", "reading_order": 38 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 412.32, "t": 349.32, "r": 540.24, "b": 329.64 }, "text": "Telephone", "field_kind": "text", "label": "Telephone", "pdf_field_name": "Telephone_3", "pdf_field_type": "Text", "reading_order": 39 }, { "page": 2, "type": "TEXT", "location": { "l": 70.32, "t": 308.4, "r": 540.24, "b": 297.36 }, "text": "*****", "reading_order": 40 }, { "page": 2, "type": "TEXT", "location": { "l": 69.36, "t": 288, "r": 541.68, "b": 272.64 }, "text": "Employer:_____", "reading_order": 41 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 121.2, "t": 295.56, "r": 540.24, "b": 275.88 }, "text": "Employer", "field_kind": "text", "label": "Employer", "pdf_field_name": "Employer_4", "pdf_field_type": "Text", "reading_order": 42 }, { "page": 2, "type": "TEXT", "location": { "l": 69.12, "t": 266.64, "r": 541.44, "b": 252.24 }, "text": "Address: ___", "reading_order": 43 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 113.88, "t": 274.92, "r": 540.24, "b": 255.36 }, "text": "Address", "field_kind": "text", "label": "Address", "pdf_field_name": "Address_4", "pdf_field_type": "Text", "reading_order": 44 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 148.68, "t": 254.52, "r": 540.24, "b": 234.84 }, "text": "Official job title", "field_kind": "text", "label": "Official job title", "pdf_field_name": "Official job title_4", "pdf_field_type": "Text", "reading_order": 45 }, { "page": 2, "type": "TEXT", "location": { "l": 69.6, "t": 246.48, "r": 147.6, "b": 231.84 }, "text": "Official job title:", "reading_order": 46 }, { "page": 2, "type": "TEXT", "location": { "l": 69.36, "t": 225.84, "r": 541.2, "b": 211.44 }, "text": "Dates of employment: ___", "reading_order": 47 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 172.56, "t": 234, "r": 540.24, "b": 214.32 }, "text": "Dates of employment", "field_kind": "text", "label": "Dates of employment", "pdf_field_name": "Dates of employment_3", "pdf_field_type": "Text", "reading_order": 48 }, { "page": 2, "type": "TEXT", "location": { "l": 69.36, "t": 205.92, "r": 541.68, "b": 190.8 }, "text": "Job responsibilities: ___", "reading_order": 49 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 162.48, "t": 213.36, "r": 540.24, "b": 193.8 }, "text": "Job responsibilities", "field_kind": "text", "label": "Job responsibilities", "pdf_field_name": "Job responsibilities_4", "pdf_field_type": "Text", "reading_order": 50 }, { "page": 2, "type": "TEXT", "location": { "l": 69.6, "t": 184.32, "r": 544.8, "b": 169.92 }, "text": "Supervisor", "reading_order": 51 }, { "page": 2, "type": "TEXT", "location": { "l": 86.64, "t": 163.68, "r": 326.4, "b": 149.76 }, "text": "Name: _____", "reading_order": 52 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 124.8, "t": 172.32, "r": 324.24, "b": 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143.76, "r": 542.16, "b": 128.64 }, "text": "Telephone: _____", "reading_order": 58 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 412.32, "t": 151.8, "r": 540.24, "b": 132.12 }, "text": "Telephone", "field_kind": "text", "label": "Telephone", "pdf_field_name": "Telephone_4", "pdf_field_type": "Text", "reading_order": 59 }, { "page": 2, "type": "TEXT", "location": { "l": 257.76, "t": 61.92, "r": 353.76, "b": 47.52 }, "text": "Revised Spring 2018", "reading_order": 60 } ] }, { "page": 3, "items": [ { "page": 3, "type": "TITLE", "location": { "l": 230.16, "t": 719.04, "r": 382.32, "b": 705.6 }, "text": "Applicants to Student Teaching", "reading_order": 0, "level": 2 }, { "page": 3, "type": "TEXT", "location": { "l": 69.6, "t": 678.48, "r": 541.68, "b": 635.04 }, "text": "Student teachers must complete one term in an elementary school and the other term in a middle school or high school. 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"page": 3, "type": "TEXT", "location": { "l": 69.84, "t": 353.76, "r": 254.4, "b": 340.56 }, "text": "School district: _____\nSchool: _____", "reading_order": 29 }, { "page": 3, "type": "FORM_FIELD", "location": { "l": 141.72, "t": 360.84, "r": 252.12, "b": 342.84 }, "text": "School district", "field_kind": "text", "label": "School district", "pdf_field_name": "School district_3", "pdf_field_type": "Text", "reading_order": 30 }, { "page": 3, "type": "TEXT", "location": { "l": 285.6, "t": 353.76, "r": 541.68, "b": 341.04 }, "text": "School:", "reading_order": 31 }, { "page": 3, "type": "FORM_FIELD", "location": { "l": 324.48, "t": 360.84, "r": 540.24, "b": 342.84 }, "text": "School", "field_kind": "text", "label": "School", "pdf_field_name": "School_3", "pdf_field_type": "Text", "reading_order": 32 }, { "page": 3, "type": "FORM_FIELD", "location": { "l": 219.24, "t": 341.88, "r": 360.24, "b": 323.88 }, "text": "Accreditation/Accrediting Body", "field_kind": "text", "label": 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"field_kind": "text", "label": "Principal", "pdf_field_name": "Principal_3", "pdf_field_type": "Text", "reading_order": 38 }, { "page": 3, "type": "TEXT", "location": { "l": 358.08, "t": 315.84, "r": 540.24, "b": 301.68 }, "text": "Telephone: _____", "reading_order": 39 }, { "page": 3, "type": "FORM_FIELD", "location": { "l": 412.32, "t": 322.92, "r": 540.24, "b": 304.92 }, "text": "Telephone", "field_kind": "text", "label": "Telephone", "pdf_field_name": "Telephone_7", "pdf_field_type": "Text", "reading_order": 40 }, { "page": 3, "type": "TEXT", "location": { "l": 69.12, "t": 297.12, "r": 541.68, "b": 283.2 }, "text": "Principal's e-mail: ___", "reading_order": 41 }, { "page": 3, "type": "FORM_FIELD", "location": { "l": 156.36, "t": 303.96, "r": 540.24, "b": 285.96 }, "text": "Principal’s e-mail", "field_kind": "text", "label": "Principal’s e-mail", "pdf_field_name": "Principals email_3", "pdf_field_type": "Text", "reading_order": 42 }, { "page": 3, "type": "TITLE", "location": { "l": 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I further verify that I am employed full-time as a Special Education Teacher at this site.", "reading_order": 62 }, { "page": 4, "type": "TEXT", "location": { "l": 70.56, "t": 208.08, "r": 541.68, "b": 194.64 }, "text": "Applicant's signature: ___", "reading_order": 63 }, { "page": 4, "type": "FORM_FIELD", "location": { "l": 172.096, "t": 219.154, "r": 396.883, "b": 195.95 }, "text": "Applicant’s signature:", "field_kind": "signature", "label": "Applicant’s signature:", "pdf_field_name": "Signature34", "pdf_field_type": "Signature", "reading_order": 64 }, { "page": 4, "type": "FORM_FIELD", "location": { "l": 459.96, "t": 215.4, "r": 540.24, "b": 197.4 }, "text": "Date", "field_kind": "text", "label": "Date", "pdf_field_name": "Date_2", "pdf_field_type": "Text", "reading_order": 65 }, { "page": 4, "type": "TEXT", "location": { "l": 430.32, "t": 207.6, "r": 541.68, "b": 195.36 }, "text": "Date: ___", "reading_order": 66 }, { "page": 4, "type": "TITLE", "location": { "l": 69.6, "t": 170.16, "r": 171.84, "b": 157.2 }, "text": "Principal's statement:", "reading_order": 67, "level": 2 }, { "page": 4, "type": "TEXT", "location": { "l": 68.64, "t": 151.92, "r": 539.52, "b": 100.32 }, "text": "I verify that this applicant is employed full-time as a Special Education Teacher at this site and that he or she has my permission and support to complete his or her alternative certification practicum here, during the next academic semester (fall or spring).", "reading_order": 68 }, { "page": 4, "type": "FORM_FIELD", "location": { "l": 170.645, "t": 102.651, "r": 397.367, "b": 75.0965 }, "text": "Principal’s signature:", "field_kind": "signature", "label": "Principal’s signature:", "pdf_field_name": "Signature35", "pdf_field_type": "Signature", "reading_order": 69 }, { "page": 4, "type": "FORM_FIELD", "location": { "l": 457.31, "t": 102.651, "r": 541.907, "b": 75.0965 }, "text": "Date:", "field_kind": "text", "label": "Date:", "pdf_field_name": "Text36", "pdf_field_type": "Text", "reading_order": 70 }, { "page": 4, "type": "TEXT", "location": { "l": 69.84, "t": 88.32, "r": 171.12, "b": 75.36 }, "text": "Principal's signature:", "reading_order": 71 }, { "page": 4, "type": "TEXT", "location": { "l": 430.32, "t": 88.08, "r": 458.4, "b": 76.56 }, "text": "Date:", "reading_order": 72 }, { "page": 4, "type": "TEXT", "location": { "l": 258, "t": 61.44, "r": 353.76, "b": 48.48 }, "text": "Revised Spring 2018", "reading_order": 73 } ] }, { "page": 5, "items": [ { "page": 5, "type": "TEXT", "location": { "l": 88.08, "t": 693.84, "r": 533.28, "b": 599.04 }, "text": "Necessity, Function, and Conformity: KRS 161.028 requires that the Education Professional Standards Board develop a professional code of ethics. This administrative regulation establishes the code of ethics for Kentucky school certified personnel and establishes that violation of the code of ethics may be grounds for revocation or suspension of Kentucky certification for professional school personnel by the Education Professional Standards Board.", "reading_order": 0 }, { "page": 5, "type": "TITLE", "location": { "l": 86.64, "t": 588.48, "r": 366.48, "b": 574.08 }, "text": "Section 1. Certified personnel in the Commonwealth:", "reading_order": 1, "level": 2 }, { "page": 5, "type": "LIST_ITEM", "location": { "l": 87.12, "t": 562.8, "r": 527.52, "b": 534 }, "text": "Shall strive toward excellence, recognize the importance of the pursuit of truth, nurture democratic citizenship, and safeguard the freedom to learn and to teach;", "marker": "(1)", "list_id": "L1", "level": 0, "reading_order": 2 }, { "page": 5, "type": "LIST_ITEM", "location": { "l": 87.6, "t": 528.96, "r": 485.28, "b": 500.16 }, "text": "Shall believe in the worth and dignity of each human being and in educational opportunities for all;", "marker": "(2)", "list_id": "L1", "level": 0, "reading_order": 3 }, { "page": 5, "type": "LIST_ITEM", "location": { "l": 87.84, "t": 495.6, "r": 508.8, "b": 466.8 }, "text": "Shall strive to uphold the responsibilities of the education profession, including the following obligations to students, to parents, and to the education profession:", "marker": "(3)", "list_id": "L1", "level": 0, "reading_order": 4 }, { "page": 5, "type": "TITLE", "location": { "l": 87.84, "t": 441.84, "r": 174.48, "b": 427.44 }, "text": "(a) To Students:", "reading_order": 5, "level": 2 }, { "page": 5, "type": "LIST_ITEM", "location": { "l": 88.32, "t": 416.16, "r": 540.24, "b": 387.84 }, "text": "Shall provide students with professional education services in a nondiscriminatory manner and in consonance with accepted best practice known to the educator;", "marker": "1.", "list_id": "L2", "level": 0, "reading_order": 6 }, { "page": 5, "type": "LIST_ITEM", "location": { "l": 87.12, "t": 382.56, "r": 357.36, "b": 368.16 }, "text": "Shall respect the constitutional rights of all students;", "marker": "2.", "list_id": "L2", "level": 0, "reading_order": 7 }, { "page": 5, "type": "LIST_ITEM", "location": { "l": 87.6, "t": 362.64, "r": 530.64, "b": 334.56 }, "text": "Shall take reasonable measures to protect the health, safety, and emotional well-being of students;", "marker": "3.", "list_id": "L2", "level": 0, "reading_order": 8 }, { "page": 5, "type": "LIST_ITEM", "location": { "l": 87.36, "t": 329.04, "r": 534.96, "b": 313.92 }, "text": "Shall not use professional relationships or authority with students for personal advantage;", "marker": "4.", "list_id": "L2", "level": 0, "reading_order": 9 }, { "page": 5, "type": "LIST_ITEM", "location": { "l": 87.12, "t": 309.36, "r": 540.24, "b": 267.6 }, "text": "Shall keep in confidence information about students which has been obtained in the course of professional service, unless disclosure serves professional purposes or is required by law;", "marker": "5.", "list_id": "L2", "level": 0, "reading_order": 10 }, { "page": 5, "type": "LIST_ITEM", "location": { "l": 86.88, "t": 261.6, "r": 515.76, "b": 247.2 }, "text": "Shall not knowingly make false or malicious statements about students or colleagues;", "marker": "6.", "list_id": "L2", "level": 0, "reading_order": 11 }, { "page": 5, "type": "LIST_ITEM", "location": { "l": 87.84, "t": 241.92, "r": 485.28, "b": 227.28 }, "text": "Shall refrain from subjecting students to embarrassment or disparagement; and", "marker": "7.", "list_id": "L2", "level": 0, "reading_order": 12 }, { "page": 5, "type": "LIST_ITEM", "location": { "l": 87.84, "t": 222.24, "r": 539.52, "b": 150.96 }, "text": "Shall not engage in any sexually related behavior with a student with or without consent, but shall maintain a professional approach with students. Sexually related behavior shall include such behaviors as sexual jokes; sexual remarks; sexual kidding or teasing; sexual innuendo; pressure for dates or sexual favors; inappropriate physical touching, kissing, or grabbing; rape; threats of physical harm; and sexual assault.", "marker": "8.", "list_id": "L2", "level": 0, "reading_order": 13 }, { "page": 5, "type": "TITLE", "location": { "l": 88.08, "t": 127.2, "r": 169.92, "b": 113.28 }, "text": "(b) To Parents:", "reading_order": 14, "level": 2 }, { "page": 5, "type": "LIST_ITEM", "location": { "l": 88.32, "t": 105.6, "r": 518.64, "b": 77.52 }, "text": "1. Shall make reasonable effort to communicate to parents information which should be revealed in the interest of the student;", "marker": "1.", "list_id": "L3", "level": 0, "reading_order": 15 }, { "page": 5, "type": "TEXT", "location": { "l": 257.76, "t": 61.68, "r": 353.28, "b": 48.24 }, "text": "Revised Spring 2018", "reading_order": 16 } ] }, { "page": 6, "items": [ { "page": 6, "type": "LIST_ITEM", "location": { "l": 86.88, "t": 719.28, "r": 517.68, "b": 691.2 }, "text": "Shall endeavor to understand community cultures and diverse home environments of students;", "marker": "2.", "list_id": "L3", "level": 0, "reading_order": 0 }, { "page": 6, "type": "LIST_ITEM", "location": { "l": 87.12, "t": 685.68, "r": 494.16, "b": 671.04 }, "text": "Shall not knowingly distort or misrepresent facts concerning educational issues;", "marker": "3.", "list_id": "L3", "level": 0, "reading_order": 1 }, { "page": 6, "type": "LIST_ITEM", "location": { "l": 87.12, "t": 665.76, "r": 520.32, "b": 637.2 }, "text": "Shall distinguish between personal views and the views of the employing educational agency;", "marker": "4.", "list_id": "L3", "level": 0, "reading_order": 2 }, { "page": 6, "type": "LIST_ITEM", "location": { "l": 87.36, "t": 632.16, "r": 539.52, "b": 604.08 }, "text": "Shall not interfere in the exercise of political and citizenship rights and responsibilities of others;", "marker": "5.", "list_id": "L3", "level": 0, "reading_order": 3 }, { "page": 6, "type": "LIST_ITEM", "location": { "l": 87.36, "t": 598.8, "r": 505.92, "b": 570.24 }, "text": "Shall not use institutional privileges for private gain, for the promotion of political candidates, or for partisan political activities; and", "marker": "6.", "list_id": "L3", "level": 0, "reading_order": 4 }, { "page": 6, "type": "LIST_ITEM", "location": { "l": 88.08, "t": 564.96, "r": 506.64, "b": 536.16 }, "text": "Shall not accept gratuities, gifts, or favors that might impair or appear to impair professional judgment, and shall not offer any of these to obtain special advantage.", "marker": "7.", "list_id": "L3", "level": 0, "reading_order": 5 }, { "page": 6, "type": "TITLE", "location": { "l": 87.84, "t": 511.92, "r": 256.56, "b": 497.52 }, "text": "(c) To the Education Profession:", "reading_order": 6, "level": 2 }, { "page": 6, "type": "LIST_ITEM", "location": { "l": 86.88, "t": 486, "r": 518.88, "b": 471.36 }, "text": "Shall exemplify behaviors which maintain the dignity and integrity of the profession;", "marker": "1.", "list_id": "L4", "level": 0, "reading_order": 7 }, { "page": 6, "type": "LIST_ITEM", "location": { "l": 86.88, "t": 466.08, "r": 535.44, "b": 437.52 }, "text": "Shall accord just and equitable treatment to all members of the profession in the exercise of their professional rights and responsibilities;", "marker": "2.", "list_id": "L4", "level": 0, "reading_order": 8 }, { "page": 6, "type": "LIST_ITEM", "location": { "l": 87.6, "t": 432.72, "r": 504, "b": 403.92 }, "text": "Shall keep in confidence information acquired about colleagues in the course of employment, unless disclosure serves professional purposes or is required by law;", "marker": "3.", "list_id": "L4", "level": 0, "reading_order": 9 }, { "page": 6, "type": "LIST_ITEM", "location": { "l": 87.12, "t": 398.88, "r": 532.56, "b": 370.8 }, "text": "Shall not use coercive means or give special treatment in order to influence professional decisions;", "marker": "4.", "list_id": "L4", "level": 0, "reading_order": 10 }, { "page": 6, "type": "LIST_ITEM", "location": { "l": 87.12, "t": 365.76, "r": 525.36, "b": 336.24 }, "text": "Shall apply for, accept, offer, or assign a position or responsibility only on the basis of professional preparation and legal qualifications; and", "marker": "5.", "list_id": "L4", "level": 0, "reading_order": 11 }, { "page": 6, "type": "LIST_ITEM", "location": { "l": 87.12, "t": 331.68, "r": 539.04, "b": 302.64 }, "text": "Shall not knowingly falsify or misrepresent records of facts relating to the educator's own qualifications or those of other professionals.", "marker": "6.", "list_id": "L4", "level": 0, "reading_order": 12 }, { "page": 6, "type": "TEXT", "location": { "l": 86.88, "t": 278.88, "r": 527.52, "b": 223.2 }, "text": "Section 2. Violation of this administrative regulation may result in cause to initiate proceedings for revocation or suspension of Kentucky certification as provided in KRS 161.120 and 704 KAR 20:585. (21 Ky.R. 2344; eff. 5-4-95; recodified from 704 KAR 20:680, 7-2-2002.)", "reading_order": 13 }, { "page": 6, "type": "TEXT", "location": { "l": 69.12, "t": 190.8, "r": 435.12, "b": 176.4 }, "text": "Printed Name: _____", "reading_order": 14 }, { "page": 6, "type": "FORM_FIELD", "location": { "l": 144.6, "t": 208.08, "r": 432.24, "b": 179.28 }, "text": "Printed Name", "field_kind": "text", "label": "Printed Name", "pdf_field_name": "Printed Name", "pdf_field_type": "Text", "reading_order": 15 }, { "page": 6, "type": "TEXT", "location": { "l": 69.84, "t": 139.68, "r": 398.64, "b": 124.8 }, "text": "Signature: _____\nDate: _____", "reading_order": 16 }, { "page": 6, "type": "FORM_FIELD", "location": { "l": 124.32, "t": 156.36, "r": 396.24, "b": 127.56 }, "text": "Signature", "field_kind": "signature", "label": "Signature", "pdf_field_name": "Signature", "pdf_field_type": "Signature", "reading_order": 17 }, { "page": 6, "type": "TEXT", "location": { "l": 429.36, "t": 139.2, "r": 541.68, "b": 125.04 }, "text": "Date:", "reading_order": 18 }, { "page": 6, "type": "FORM_FIELD", "location": { "l": 461.16, "t": 156.36, "r": 540.24, "b": 127.56 }, "text": "Date", "field_kind": "text", "label": "Date", "pdf_field_name": "Date_4", "pdf_field_type": "Text", "reading_order": 19 }, { "page": 6, "type": "TEXT", "location": { "l": 258.24, "t": 61.92, "r": 353.28, "b": 48 }, "text": "Revised Spring 2018", "reading_order": 20 } ] }, { "page": 7, "items": [ { "page": 7, "type": "TEXT", "location": { "l": 97.68, "t": 708.96, "r": 120, "b": 700.56 }, "text": "Page 3", "reading_order": 0 }, { "page": 7, "type": "TITLE", "location": { "l": 218.4, "t": 685.92, "r": 400.8, "b": 675.12 }, "text": "SECTION III. CHARACTER AND FITNESS", "reading_order": 1, "level": 1 }, { "page": 7, "type": "TEXT", "location": { "l": 97.2, "t": 664.56, "r": 521.04, "b": 636.96 }, "text": "(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)", "reading_order": 2 }, { "page": 7, "type": "TEXT", "location": { "l": 97.92, "t": 630.24, "r": 517.68, "b": 620.16 }, "text": "Name: ___ Social Security Number: ___", "reading_order": 3 }, { "page": 7, "type": "FORM_FIELD", "location": { "l": 122.4, "t": 637.44, "r": 253.999, "b": 621.36 }, "text": "Nrune", "field_kind": "text", "label": "Nrune", "pdf_field_name": "Nrune", "pdf_field_type": "Text", "reading_order": 4 }, { "page": 7, "type": "FORM_FIELD", "location": { "l": 348, "t": 637.44, "r": 514.773, "b": 621.36 }, "text": "Social Security Number", "field_kind": "text", "label": "Social Security Number", "pdf_field_name": "Social Security Number", "pdf_field_type": "Text", "reading_order": 5 }, { "page": 7, "type": "TEXT", "location": { "l": 97.92, "t": 612.72, "r": 517.2, "b": 603.36 }, "text": "Address: ___", "reading_order": 6 }, { "page": 7, "type": "FORM_FIELD", "location": { "l": 130.32, "t": 619.68, "r": 516.909, "b": 603.6 }, "text": "Address", "field_kind": "text", "label": "Address", "pdf_field_name": "Address_5", "pdf_field_type": "Text", "reading_order": 7 }, { "page": 7, "type": "TEXT", "location": { "l": 99.12, "t": 602.88, "r": 510.72, "b": 594.48 }, "text": "(City) (State) (Zip Code)", "reading_order": 8 }, { "page": 7, "type": "TEXT", "location": { "l": 188.16, "t": 602.64, "r": 209.76, "b": 595.2 }, "text": "(Street)", "reading_order": 9 }, { "page": 7, "type": "TEXT", "location": { "l": 97.68, "t": 588.48, "r": 517.2, "b": 578.4 }, "text": "Telephone Number: ( )", "reading_order": 10 }, { "page": 7, "type": "FORM_FIELD", "location": { "l": 194.4, "t": 595.68, "r": 514.625, "b": 579.6 }, "text": "Telephone Number", "field_kind": "text", "label": "Telephone Number", "pdf_field_name": "Telephone Number", "pdf_field_type": "Text", "reading_order": 11 }, { "page": 7, "type": "TEXT", "location": { "l": 97.2, "t": 570.24, "r": 517.68, "b": 551.52 }, "text": "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.", "reading_order": 12 }, { "page": 7, "type": "TEXT", "location": { "l": 98.4, "t": 544.08, "r": 518.64, "b": 524.88 }, "text": "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:", "reading_order": 13 }, { "page": 7, "type": "TEXT", "location": { "l": 120.96, "t": 520.32, "r": 518.4, "b": 506.4 }, "text": "State or Jurisdiction ___ Certificate Number ___", "reading_order": 14 }, { "page": 7, "type": "FORM_FIELD", "location": { "l": 187.44, "t": 525.36, "r": 302.64, "b": 509.28 }, "text": "State .or Jurisdictien", "field_kind": "text", "label": "State .or Jurisdictien", "pdf_field_name": "State or Jurisdictien", "pdf_field_type": "Text", "reading_order": 15 }, { "page": 7, "type": "FORM_FIELD", "location": { "l": 366.72, "t": 525.12, "r": 514.625, "b": 509.04 }, "text": "Certificate Number", "field_kind": "text", "label": "Certificate Number", "pdf_field_name": "Certificate Number", "pdf_field_type": "Text", "reading_order": 16 }, { "page": 7, "type": "TEXT", "location": { "l": 121.2, "t": 501.36, "r": 517.92, "b": 489.6 }, "text": "Type ___ Issue Date ___ Expiration Date ___", "reading_order": 17 }, { "page": 7, "type": "FORM_FIELD", "location": { "l": 268.08, "t": 507.84, "r": 355.241, "b": 491.76 }, "text": "Issue Date", "field_kind": "text", "label": "Issue Date", "pdf_field_name": "Issue Date", "pdf_field_type": "Text", "reading_order": 18 }, { "page": 7, "type": "FORM_FIELD", "location": { "l": 141.84, "t": 507.6, "r": 230.64, "b": 491.52 }, "text": "Type", "field_kind": "text", "label": "Type", "pdf_field_name": "Type", "pdf_field_type": "Text", "reading_order": 19 }, { "page": 7, "type": "FORM_FIELD", "location": { "l": 412.32, "t": 507.6, "r": 517.011, "b": 491.52 }, "text": "Expiration Date", "field_kind": "text", "label": "Expiration Date", "pdf_field_name": "Expiration Date", "pdf_field_type": "Text", "reading_order": 20 }, { "page": 7, "type": "LIST_ITEM", "location": { "l": 96.24, "t": 482.88, "r": 521.76, "b": 462.96 }, "text": "Have you ever had a professional certificate, license, credential, or any document issued to you for practice denied, suspended, revoked, or voluntarily surrendered?", "marker": "1.", "list_id": "L5", "level": 0, "reading_order": 21 }, { "page": 7, "type": "LIST_ITEM", "location": { "l": 96.48, "t": 456.48, "r": 520.56, "b": 437.04 }, "text": "Are you currently being reviewed or investigated for purposes of such action as stated in #1 or is such action pending?", "marker": "2.", "list_id": "L5", "level": 0, "reading_order": 22 }, { "page": 7, "type": "LIST_ITEM", "location": { "l": 95.28, "t": 430.32, "r": 522.96, "b": 402 }, "text": "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?", "marker": "3.", "list_id": "L5", "level": 0, "reading_order": 23 }, { "page": 7, "type": "LIST_ITEM", "location": { "l": 95.28, "t": 395.04, "r": 521.04, "b": 383.28 }, "text": "Is any such action as stated in #3 pending? Yes No", "marker": "4.", "list_id": "L5", "level": 0, "reading_order": 24 }, { "page": 7, "type": "LIST_ITEM", "location": { "l": 93.84, "t": 376.8, "r": 523.92, "b": 347.28 }, "text": "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?", "marker": "5.", "list_id": "L5", "level": 0, "reading_order": 25 }, { "page": 7, "type": "LIST_ITEM", "location": { "l": 96.48, "t": 342.48, "r": 520.08, "b": 321.6 }, "text": "If you indicated \"yes\" to any items, #1 through #6, has that action been reviewed. Yes No by the Education Professional Standards Board?", "marker": "6.", "list_id": "L5", "level": 0, "reading_order": 26 }, { "page": 7, "type": "FORM_FIELD", "location": { "l": 283.2, "t": 332.88, "r": 402.24, "b": 325.44 }, "text": "by the Educatien Prefessional Standards Board", "field_kind": "text", "label": "by the Educatien Prefessional Standards Board", "pdf_field_name": "by the Educatien Prefessional Standards Board", "pdf_field_type": "Text", "reading_order": 27 }, { "page": 7, "type": "TEXT", "location": { "l": 314.4, "t": 324.24, "r": 371.52, "b": 315.6 }, "text": "(Date of Review)", "reading_order": 28 }, { "page": 7, "type": "TEXT", "location": { "l": 96, "t": 308.16, "r": 514.56, "b": 270.72 }, "text": "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.", "reading_order": 29 }, { "page": 7, "type": "TEXT", "location": { "l": 93.12, "t": 264.48, "r": 512.88, "b": 236.4 }, "text": "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.", "reading_order": 30 }, { "page": 7, "type": "TEXT", "location": { "l": 96.96, "t": 222, "r": 380.64, "b": 209.76 }, "text": "SIGNATURE___\nDATE ___", "reading_order": 31 }, { "page": 7, "type": "FORM_FIELD", "location": { "l": 148.043, "t": 233.078, "r": 377.355, "b": 211.68 }, "text": "SIGNATURE", "field_kind": "signature", "label": "SIGNATURE", "pdf_field_name": "SIGNATURE", "pdf_field_type": "Signature", "reading_order": 32 }, { "page": 7, "type": "TEXT", "location": { "l": 391.44, "t": 223.92, "r": 517.92, "b": 210 }, "text": "DATE", "reading_order": 33 } ] } ]