Davenport's Urban Education Graduate Certificate Supplement

Name

Phone

Address

Address 2

City/Town

State

ZIP/Postal Code

Country

Are You a Current Davenport Student?

Yes

Davenport Student ID

Upload your resume

One file only.
8 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

Current Employer (if employed by a school)

Michigan Department of Education Personal Identification Code (PIC), if applicable

Conviction/Revocation information

1. Have you ever accepted responsibility in a civil infraction (excluding speeding tickets) or been convicted of (or pled no contest to) a misdemeanor or felony?

Yes

2. Have you ever had a professional certification or licensure suspended or revoked (including, but not limited to, teaching/school counselor/school psychologist)?

Yes

3. Is there currently action pending against your professional certification or licensure (including, but not limited to, teaching/school counselor/school psychologist)?

Yes

4. Have you ever surrendered a professional certification or licensure (including, but not limited to teaching/school counselor/school psychologist)?

Yes

If you answered yes to any of the questions above, please provide a detailed description of the circumstances surrounding the conviction or action and attach copies of court documents. Additionally, you must submit this documentation to the MDE at the time of the recommendation for the Michigan teaching certificate.

Attach court documents

One file only.
8 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Criminal Background

Per Michigan Revised School Code Section 1230, school districts, intermediate school districts or public school academies require a criminal background check as part of employment. You are also responsible for ensuring your background check and fingerprinting have been completed prior to serving in any of the aforementioned institutions/organizations. If you have been convicted of a felony, you may not be able to achieve employment in a school or school district in the State of Michigan, and a criminal history could stand in the way of practicum participation, internship participation, licensure, and employment.

I have read and understand the statement regarding criminal background. I understand that it is my responsibility to consider possible impacts of a criminal background check on licensure, practicum and internship placement, and employment opportunities.

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