OFFICE OF SUPERINTENDENT OF PUBLIC INSTRUCTION
Professional Certification
Old Capitol Building, PO BOX 47200
OLYMPIA WA 98504-7200
(360) 725-6400 TTY (360) 664-3631
Web Site: http:/ /www.k12.wa.us/certification
E-Mail: cert@k12.wa.us
Date
ESD No.
APPLICATION FOR WASHINGTON STATE
CAREER AND TECHNICAL EDUCATION
ENDORSEMENT (Specialty Area)
Fee $40
Receipt No.
NOTE: This application is for those who hold a VALID Washington CTE teaching certificate and want to add a
specialty area based on completion of verification of occupational experience.
CHECKLIST:
Form SPI/CTEcert 4075A-1 Application for adding a specialty area to CTE certificate
Fee $1.00 plus $39.00 OSPI = $40.00 made payable to OSPI
Verification by letter from employer or tax return(s) for occupational experience
Please complete the following and sign the affidavit.
CTE Specialty area(s) requested:
Specialty Area Name and VCODE _________________ Specialty Area Name and VCODE ________________
1.
NAME
2.
ADDRESS
LAST
FIRST
MIDDLE
3. DATE OF BIRTH
CITY/STATE/ZIP
5.
4. SOCIAL SECURITY NO. (OPTIONAL)
TELEPHONE:
BUSINESS (
MAIDEN/FORMER NAME
6. E-MAIL
)
HOME (
)
8. CERTIFICATE NO.
*Business and Industry Route-Verify three (6,000 hours) of paid occupational experience in the subcategory specialty
CTE field. One year (2,000 hours) must have been completed within the past six years.
*If all or part of the 2,000 hours is more than 6 years old, an additional 300 hours of recent occupational experience
(occurring in the past two years) is required.
ATTACH YOUR CHECK TO THIS FORM.
CAREER AND TECHNICAL EDUCATION CERTIFICATION USE ONLY
APPROVED BY
CERTIFICATE TYPE(S)
DATE
PROB.
G-General
S-Specific
ISSUE DATE
DATE CERTIFICATE MAILED
EXPIRATION DATE
CLASSIFICATION
4 - New
2 - Renewal
FORM SPI/VCERT 4075A-1 (Rev. 9/15)
Page 1 of 3
TO BE COMPLETED BY APPLICANT
Verification of paid occupational experience in the specific career and technical education certificated field is required. Listed
employment must be verified by letter from the employer or by tax returns. Self-employment must be verified by submitting a copy of
your business license, tax return, or letters from clients. If teaching is used complete the Teaching Experience form (4075H).
Occupation
Dates of Employment
Total Number of Paid Hours
Duties
Employer
Address
City
State
Zip Code
Telephone Number
Occupation
Dates of Employment
Total Number of Paid Hours
Duties
Employer
Address
City
State
Zip Code
Telephone Number
Occupation
Dates of Employment
Total Number of Paid Hours
Duties
Employer
Address
City
State
Zip Code
Telephone Number
Occupation
Dates of Employment
Total Number of Paid Hours
Duties
Employer
Address
City
State
Zip Code
Telephone Number
Total Number of Paid
Hours
for All Listed Employers
AFFIDAVIT
I, _____________________________, certify (or declare) under penalty of perjury under the laws of the State of Washington that
the foregoing and all information included in this application is true and correct. If the answers to any question on the application or
the moral character and personal fitness section on the application change prior to my being granted certification, I must
immediately notify Career and Technical Education Certification at OSPI.
Signature
FORM SPI/VCERT 4075A-1 (Rev. 9/15)
Date
City/State
Page 2 of 3
The following specialties area certificates are based on completion of the Business and Industry Route:
V010101
V010201
V010300
V010303
V010601
V091001
V520100
V520300
V520403
V520404
V080102
V600097
V510700
V510710
V510800
V510900
V120403
V120505
V160103
V190403
V190504
V190601
V190707
V100100
V143501
V141801
V150100
V280300
V430100
V430106
V430203
V460200
V460302
V460401
V470101
V470201
AGRICULTURE
Subcategory Specialty Areas for Agriculture Education
Agribusiness
V010603 Floriculture
Agricultural Mechanics
V011001 Agriculture Food Science
Agricultural Production
V030101 Natural Resources
Aquaculture
V410301 Chemical Technology
Horticulture
V510808 Veterinarian Assistant
BUSINESS AND MARKETING
Publishing
V520895 Banking Support Services
Business Management
V521206 Computer Applications & Related Programs
Accounting and Related Programs
V080301 Entrepreneurship
Legal Administrative Services
V080706 General Sales Operations
Medical Administrative Services
V520902 Lodging Management
Fashion Merchandising
V521401 Marketing Management
WORK SITE LEARNING
CAREER CHOICES
Worksite Learning (Must also hold a CTE
V600092 Career Choices (Must also be certificated for
Teaching Certificate)
Worksite Learning)
HEALTH SCIENCE
Health Infomatic Careers
V510601 Dental Assisting
Health Support Services Careers
V510709 Sports Medicine
Health Therapeutic Careers
V511614 Nursing Assisting
Health Diagnostic Careers
V260102 Biomedical Science
V261202 Health Science Biotechnology
HUMAN SERVICES
Cosmetology
V190708 Early Childhood Education and Services
Food Production and Services
V190901 Textiles and Apparel
Translation and Interpretation
V200206 Educational Para Pro
Consumer Services
V200212 Careers in Education
Food Science Dietetics and Nutrition
V200493 Culinary Arts
Housing, Interiors and Furnishings
V310101 Hospitality, Recreation and Tourism
Family and Community Services
V510205 Sign Language Interpreter
SKILLS AND TECHNOLOGY SCIENCES
Communication Technologies
V470110 Computer Technology
Engineering
V470201 Refrigeration/Air-Conditioning/Heating
Material Engineering
V470600 Automotive Technology
Manufacturing Technology
V470603 Auto Body Repair
JROTC
V470608 Aircraft Technician
Criminal Protective Services
V480101 Drafting
Forensic Technology
V480500 Precision Metal Worker
Fire Service
V490100 Aviation Occupations
Construction Trades
V490300 Water Transportation/Worker
Electrician
V500400 Commercial Design/Applied Art
Building Maintenance Technician
V500502 Stage Design Technician
Electrical and Electronic Equipment Repair
V141000 STEM Technology
Refrigeration/Air-Conditioning/Heating
4075 Req. (Rev. 9/15)
Page 3 of 3
OFFICE OF SUPERINTENDENT OF PUBLIC INSTRUCTION
Professional Certification
Old Capitol Building, PO BOX 47200
OLYMPIA WA 98504-7200
(360) 725-6400 TTY (360) 664-3631
Web Site: http:/ /www.k12.wa.us/certification
E-Mail: cert@k12.wa.us
CAREER AND TECHNICAL EDUCATION CERTIFICATE
VERIFICATION OF SPECIFIC SAFETY
USE THIS FORM ONLY IF YOU HAVE NOT COMPLETED A COLLEGE/UNIVERSITY STATE-APPROVED CAREER AND
TECHNICAL EDUCATION TRAINING PROGRAM.
TO BE COMPLETED BY APPLICANT
1. NAME
LAST
FIRST
MIDDLE
2. ADDRESS
3. DATE OF BIRTH
CITY/STATE/ZIP
5. TELEPHONE
BUSINESS
MAIDEN/FORMER NAME
(
4. SOCIAL SECURITY NO. (OPTIONAL)
)
HOME
(
)
E-MAIL
Career and technical education teaching program area
Answer the following:
1.
2.
What safety training have you had for this occupation?
List safety and hygiene issues related to this specific occupation or trade.
3.
How would you teach safety to secondary students for this specific occupation or trade?
4.
How will you document or verify that students understand and follow safety practices in a classroom lab?
Attach additional pages if necessary.
FORM SPI/VCERT 4075S-1 (Rev. 9/15)
Page 1