(1/80)
Stat: of Washington
a 30 .4 3.-int ?t

For School Use Only
;Ri2 section may be completed\
if a rush ig, esired by Lhe

.-

   

I Stata of Hashington employin El district.
Superintendent of Public instruction 
Olympia, Hashington Suggfint ndent?s Signature
Name of District801denda18 
SchooI District'?m?f?_ 

  
   
    
 



other accompanying materials (as 

Certification and Licens'ng, 01d Capitol
nal scrvi?c d'strict off' . ith check or

I

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4 ?Ivuvia, WA 9850& or bu sent to an
Irivr attached.

.vrtificatc requehted:

 
  
  
 
   
 
 

Initial (reciprocity based on 
teacher education program)
Initial (reciprocity based on

experience}
Initial (without reciprocity

~:i:uca

   

vvrtificntion:

.


 

   

 

 

other iegal names under which your file

Have you ever held any kind of Washington certification?
23 certificate number

C;n L161n11?xl?i,r

(city)

 

1.0,

 



(state)

?77} may

(zip code) (telephoney?

birth ABLE). 30',  Place of hi th PAI'faczz/rpAfa.   

985,20

you citizen of the United 

 

 

If not, have you declared yOur intention to 3

?Iz?t?amv: a citizen? When? 



5.: in last {on years have you ever pled guxity, been convicted, fined, imprisoned or "a

. i ?~44
. x, 


probation {or violation of any law, polxce regulation 0r ordinance (excluding 

HGT I
I
.t?latxons for a flne or forfeiture of $100 or less was imposed)? ?No hf [a



Yes


?int

last ten wears have ou ever been dischar cd or forced to resi for misco duct '5
. 

 

 

 

 

 

 

 

unantisfactary service from any position teaching or other? Yes Ho 
?u

ever had a certificate revoked, suspnn3:3 or denied, or have you -
hed a teaching Certificate to avoid revocnt on procedures? Yes Hg -
5v. 2330 of state :f


7 (J [3 

w- . ??ugu WW .. 1 

*1 5* o: Lertiftcatson and LlconSIng nnly: 

I Hailed?kw-?mv?AA-wu? 



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