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The Word: Online Notification Form

RETURN FORM TO:

  • NAZARETH COLLEGE - CERTIFICATION OFFICE (GAC 298)
    4245 EAST AVENUE
    ROCHESTER, NY 14618-3790

QUESTIONS CONTACT: GEORGEANN POTEMPA
PHONE #: 585-389-2592 (E-MAIL: gpotemp2@naz.edu)

COLLEGE FORM TO BE RETURNED BY STUDENTS APPLYING ON-LINE

"APPROVED TEACHER PREPARATION PATHWAY"

APPLYING FOR: (circle)

  • INITIAL
  • PROFESSIONAL
  • PERMANENT

CERTIFICATION AREA(S) :

The Nazareth College Certification Office will recommend you to the State Education Department for the area(s) of certification you completed your degree in after confirming your eligibility.

NAME: ( LAST)

(FIRST)

(MIDDLE)

ADDRESS:

CITY:
STATE:
ZIP:

PHONE:
SOCIAL SECUIRTY #:

E-MAIL:

DEGREE GRANTED AT NAZARETH:
DATE OF DEGREE COMPLETION:

Complete the following information that pertains to your Degrees:

COLLEGE ATTENDED

DEGREE

COMPL. DATE

1.

2.

3.

Field or areas for which you hold certification

INITIAL/PROFESSIONAL

DATE ISSUED

AREA OF CERT.

1.

2.

3.

DO NOT HOLD CERTIFICATION:

COMPLETED THE VIOLENCE PREVENTION WORKSHOP: (circle)

  • YES
  • NO

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FOR OFFICE USE ONLY
COMMENTS:

COLLEGE FM. RECEIVED

COLLEGE RECOMMENDATION

 

10/11/06