Pursuant to Public Act 68 of 1993 and Public Act 83 of 1995, please check the following
as it pertains to you:
Yes*
No
1. Have you ever been convicted of, or pled guilty or nolo contendere
(no contest) to a felony?
_____ _____
2. Have you ever been convicted of, or pled guilty or nolo contendere
(no contest) to a misdemeanor? [Exceptions: minor traffic violation.]
_____ _____
3. Have you ever had a teaching certificate denied, revoked, nullified,
or have you ever surrendered a teaching certificate?
_____ _____
4. Have you ever been convicted in Michigan or any other state
jurisdiction, whether upon a verdict or plea of guilty or upon a plea of
nolo contendere (no contest), or received a suspended sentence for a
crime or an attempt to commit a crime which is considered sexually
related in nature?
_____ _____
5. Do you currently have any outstanding criminal charges or warrants
of arrest pending against you in Michigan or any other state or
jurisdiction?
_____ _____
*NOTE: If you have answered YES for any of the above-mentioned questions, you will
Certification
Officer, Jane E. Kramer.
ADVISORY: In accordance with Public Act 96 of the Public Acts of 1995, it is a criminal
offense to use or attempt to use, a college or university transcript that is fraudulently
obtained, altered, forged, or other fraudulent credentials to obtain a teacher, school
administrator, or school psychologist certificate, or other State Board approval.
Are you requesting special accommodations under the Americans with Disabilities Act
(ADA)? [ ] Yes [ ] No If yes, please describe:
Signature _________________________________________ Date_________
Printed Name ______________________________________ Date_________