Certification - OSPI
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Certification

College/University Forms
for Certification Officers Only

Forms marked with (Cert) are for restricted use (college certification officers only).  All others are available from the Institutional Use section of the Download Forms page.
General As of
1 FEE Payment Schedule (for use with college applications only) 07/05
2 Dean's Affidavit (Cert) 05/97
3 4020B (Institutional Character and Fitness Supplement - 4 pages) 08/03
4 4020C (Verification of Good Standing for Certificates Held in Other States) 08/01
5 4020E (Institutional Verification of Program Completion and Character) 7/07
6 4020F (Continuing Certificate: Verification of Experience) 10/01
7 4020F2 (Verification of Out-of-State Experience) 02/06
8 1126 (Clock hrs-Professional Growth Team Consultation & Collaboration) (Cert) 08/03

 

Teacher
1 1535 (Institutional Application for Endorsement completed at WA college) 10/05
2 4401 (Institutional Application for Teaching Certificate) 05/09
Residency:  
3 4410-1 (pdf) (Verification List - Residency Teacher Provisional Status with Affidavit) (Cert) (Fill-in-the-blanks version) 11/07
  4410-1A (pdf) (Verification List – 5-yr Residency Teacher with Affidavit) (Cert) 04/05
4 4410-2 (pdf) (Verification List - Residency Teacher Provisional Status without Affidavit) (Cert) 11/07
  4410-2A (pdf) (Verification List – 5-yr Residency Teacher without Affidavit) (Cert) 04/05
5 4413-1 (pdf) Verification List - Residency Teacher 2-yr Renewal with Affidavit) (Cert) 01/05
6 4413-2 (pdf) (Verification List - Residency Teacher 2-yr Renewal without Affidavit) (Cert) 01/05
Initial:  
7 4412-1 (pdf) (Verification List - Renewal of Initial Certificate) (Cert) 08/00
Continuing:  
8 4411-1 (pdf) (Verification List - Continuing Certificate with Affidavit) (Cert) 12/04
9 4411-2 (pdf) (Verification List - Continuing Certificate without Affidavit) (Cert) 11/01
Professional:  

10

4421 (Institutional Form - Provisional Status/Employer Support Verification) 10/04

11

4414-1 (pdf) (Verification List - Professional Certificate with Affidavit) (Cert) 12/04

12

4414-2 (pdf) (Verification List - Professional Certificate without Affidavit) (Cert) 12/04
Endorsement:  

13

4415-1 (pdf) (Verification List - Endorsement) (Cert) 12/04

14

4415-2 (pdf) (Verification List - Endorsement via Pathway 2) (Cert) 09/05

15

4422 (pdf) (Institutional Form - Pathway 2 Pedagogy Assessment/Employer Support Verification) 03/10
Intern Substitute:  

16

4417 (pdf) (Verification List - Intern Substitute Certificate) (Cert) (Fill-in-the-blanks version)

03/01
Substitute:  

17

4418 (pdf) (Verification List - Substitute Certificate) (Cert) 09/02

 

Administrator
1 4200 (Requirements - Initial/Continuing/Residency Administrator) 10/05
2 4201 (Institutional Application for Administrator) 07/08
3 4001 F-C (Prerequisite Experience for a Principal's Certificate) 12/05
4 4201F-D (Verification of Experience for the Professional Administrator's Certificate) 11/08

Residency:  

5

4212A-1 (pdf) (Verification List - Residency Principal, First Issue) (Cert) 07/08

6

4212B-1 (pdf) (Verification List - Residency Program Administrator, First Issue) (Cert) 07/08

7

4212C (pdf) (Verification List - Residency Renewal Principal) (Cert) 09/11

8

4212C-1 (pdf) (Verification List - Residency Renewal Program Administrator) (Cert) 09/11

Initial:  

9

4210C (pdf) (Verification List - Initial Superintendent) (Cert) 07/08

Continuing:  

10

4211A1 (pdf) (Verification List - Continuing Principal if certificated since 1998) (Cert) 09/02

10

4211B (pdf) (Verification List - Continuing Program Administrator) (Cert) 05/98

12

4211C (pdf) (Verification List - Continuing Superintendent) (Cert) 05/98
  Professional Administrator:  
13 4213B (pdf) (Verification List - Professional Principal) 07/08
14 4213B-1 (pdf) (Verification List - Professional Program Administrator) 07/08
15 1656A (Word) (Professional Growth Plan for Renewal - Professional Principal and Program Administrator) 01/11
16 1656B (Word) (Record of Continuing Education - Professional Principal and Program Administrator) 01/11

 

Educational Staff Associate

School Psychologist/School Counselor:

1

4301 (pdf) (Institutional Application for ESA)

02/12

2

4301F (pdf) (Verification of ESA Experience)

3/11

3

4310A-1A (pdf) (Verification List - Initial ESA w/o cert other states) (Cert) 9/05

4

4310A-2A (pdf) (Verification List - Initial ESA w/cert in other states) (Cert) 9/05
5

4311A-1 (pdf) (Verification List - Continuing ESA w/o cert other states) (Cert)

07/95

6

4312A-1 (pdf) (Verification List - Residency ESA w/Dean's Affidavit)

9/05

7

4312A-2 (pdf) (Verification List - Residency ESA without Affidavit)

9/05

last updated: February 2012

 

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