APPLICATION FOR STUDENT TEACHING INTERN CERTIFICATE
Arizona Department Of Education - Certification Unit
Mailing Address: P.O. Box 6490, Phoenix, AZ 85005-6490 • Telephone: 602.542.4367
** REQUIREMENTS MAY BE SUBJECT TO CHANGE AND ARE FULLY REFERENCED IN THE ARIZONA REVISED STATUTES AND ADMINISTRATIVE CODE. **
4/10/2017 WWW.AZED.GOV/EDUCATOR-CERTIFICATION/ PAGE 1 OF 5
General Information
The Student Teaching Intern certificate is optional and is not a requirement for participation in a student
teaching capstone experience.
The certificate entitles the holder to perform teaching duties under the supervision of a program supervisor and
is only valid in the school district or charter school requesting the certificate.
The Student Teaching Intern certificate is valid for one year from date of initial issuance and may be extended
for one year if required.
Placement decisions of student teaching intern certificate holders shall only be based on collaborative
agreements between the Board approved educator preparation provider and the Local Education Agency
(LEA). A written supervision plan regarding onsite mentorship and induction shall be submitted by the EPP
and approved by the Board. The LEA is required to provide onsite mentorship and induction in support of the
student teaching intern certificate holder.
Notwithstanding any other provision, a Student Teaching Intern certificate holder may not teach in a special
education classroom unless the certificate holder has a bachelor’s degree.
Requirements for the Student Teaching Intern PreK-12 Certificate are:
1. A valid Arizona Department of Public Safety Identity Verified Prints (IVP) fingerprint clearance card.
2. An Educator Preparation Program (EPP) Request for Issuance of the Student Teaching Intern Certificate
which includes verification that the applicant meets the following requirements:
a. The applicant is enrolled in the culminating student teaching capstone experience of an Arizona
Board approved educator preparation program (EPP).
b. The applicant has a minimum GPA of 3.0 on a 4.0 scale or the equivalent.
c. The EPP provider has a written supervision plan regarding onsite mentorship and induction that
has been approved by the Board.
3. A District/Charter School Request for Issuance of the Student Teaching Intern Certificate signed by the
superintendent.
4. A passing score on the required professional knowledge portion of the Arizona Teacher Proficiency
Assessment that corresponds to the teaching certificate the student teaching intern is pursuing.
5. A passing score on the required subject knowledge portion of the Arizona Teacher Proficiency Assessment
that corresponds to the teaching certificate the student teaching intern is pursuing.
6. Applicants who are student teaching in a special education classroom must submit official transcripts
documenting a Bachelor’s or more advanced degree.
The holder of the student teaching certificate may apply for the Arizona Provisional Teaching Certificate upon
completion of the following:
1. Successful completion of the Board approved educator preparation program (EPP).
2. Submission of an application and all required documentation including an Institutional Recommendation
(IR) to the Arizona Department of Education, Certification Unit.
Arizona State Board of Education
Professional Practices for Certificate Holders
Standards for Imposing Certificated Educator Sanctions
Consistent with A.R.S. §15-203(20), the State Board of Education may
impose disciplinary action upon a certified individual, including a letter of
censure, suspension, suspension with conditions or revocation of a
certificate upon a finding of immoral or unprofessional conduct.
Criminal Offenses
Pursuant to administrative code R7-2-1307 and ARS § 15-550, the Board
shall revoke the certification of a person who has been convicted of or
admitted in open court or pursuant to a plea agreement any of the
following criminal offenses in this state or similar offenses in another
jurisdiction:
1. Sexual abuse of a minor
2. Incest
3. First-degree murder
4. Second degree murder
5. Manslaughter
6. Sexual assault
7. Sexual exploitation of a minor
8. Commercial sexual exploitation of a minor
9. A dangerous crime against children as defined in A.R.S. §13-
604.01
10. Armed robbery
11. Aggravated assault
12. Sexual conduct with a minor
13. Molestation of a child
14. Exploitation of minors involving drug offenses
Upon notification that a certificated individual has been convicted of a
nonrenewable offense, the Board shall revoke the certificate.
Unprofessional and Immoral Conduct
Individuals holding certificates issued by the Board pursuant to R7-2-601
and individuals applying for certificates issued by the Board pursuant to
R7-2-601 shall:
1. Make reasonable efforts to protect pupils from conditions
harmful to learning, health, or safety;
2. Account for all funds collected from pupils, parents, or school
personnel;
3. Adhere to provisions of the Uniform System of Financial
Records related to use of school property, resources, or
equipment; and
4. Abide by copyright restrictions, security, or administration
procedures for a test or assessment.
Individuals holding certificates issued by the Board pursuant to R7-2-601
and individuals applying for certificates issued by the Board pursuant to
R7-2-601 shall not:
1. Discriminate against or harass any pupil or school employee on
the basis of race, national origin, religion, sex, including sexual
orientation, disability, color or age;
2. Deliberately suppress or distort information or facts relevant to
a pupil’s academic progress;
3. Misrepresent or falsify pupil, classroom, school, or district-level
data from the administration of a test or assessment;
4. Engage in a pattern of conduct for the sole purpose or with the
sole intent of embarrassing or disparaging a pupil;
5. Use professional position or relationships with pupils, parents,
or colleagues for improper personal gain or advantage;
6. Falsify or misrepresent documents, records, or facts related to
professional qualifications or educational history or character;
7. Assist in the professional certification or employment of a
person the certificate holder knows to be unqualified to hold a
position;
8. Accept gratuities or gifts that influence judgment in the exercise
of professional duties;
9. Possess, consume, or be under the influence of alcohol on
school premises or at school-sponsored activities;
10. Illegally possess, use, or be under the influence of marijuana,
dangerous drugs, or narcotic drugs, as each is defined in A.R.S. §
13-3401;
11. Make any sexual advance towards a pupil or child, either verbal,
written, or physical;
12. Engage in sexual activity, a romantic relationship, or dating of a
pupil or child;
13. Submit fraudulent requests for reimbursement of expenses or
for pay;
14. Use school equipment to access pornographic, obscene, or
illegal materials;
15. Engage in conduct which would discredit the teaching
profession.
Individuals found to have engaged in unprofessional or immoral conduct
shall be subject to, and may be disciplined by, the Board.
Resignation as an Unprofessional Act and Penalty: ARS §15-545
A certificated teacher shall not resign after signing and returning his
contract, unless the resignation is first approved by the governing board. A
teacher who resigns contrary to this section shall be deemed to commit an
unprofessional act and, upon request of the governing board, shall be
subject to such disciplinary action, including suspension and revocation of
certificate, as the state board of education deems appropriate.
Failing to Report of Immoral or Unprofessional Conduct
Pursuant to ARS §15-514, any certificated person or governing board
member who reasonably suspects or receives a reasonable allegation that
a person certificated by the state board of education has engaged in
conduct involving minors that would be subject to the reporting
requirements of section 13-3620 (mandatory reporting) shall report or
cause reports to be made to the department of education in writing as
soon as reasonably practicable but not later than three business days after
the person first suspects or receives allegation of the conduct.
The superintendent of a school district or the chief administrator of a
charter school who reasonably suspects or receives a reasonable allegation
that an act of immoral or unprofessional conduct that would constitute
grounds for dismissal or criminal charges by a certificated person has
occurred shall report the conduct to the department of education.
Failure to report information as required in ARS §15-514 by a certificated
person constitutes grounds for disciplinary action by the state board of
education.
A governing board member or school district employee who has control
over personnel decisions and who reasonably suspects or receives a
reasonable allegation that a person certificated by the state board of
education has engaged in conduct involving minors that would be subject
to the reporting requirements of ARS §§ 13-3620 and 15-514 shall not
accept the resignation of the certificate holder until these suspicions or
allegations have been reported to the State Board of Education.
Filing a Complaint against a Certificate Holder
The Investigative Unit may be reached at (602) 542-2972 or
investigation@azed.gov
For Further Information: Call or Email
State Board of Education
(602) 542-5057 [email protected]
Updated 10/28/16
APPLICATION FOR STUDENT TEACHING INTERN CERTIFICATE
Arizona Department Of Education - Certification Unit
Mailing Address: P.O. Box 6490, Phoenix, AZ 85005-6490 • Telephone: 602.542.4367
** REQUIREMENTS MAY BE SUBJECT TO CHANGE AND ARE FULLY REFERENCED IN THE ARIZONA REVISED STATUTES AND ADMINISTRATIVE CODE. **
4/10/2017 WWW.AZED.GOV/EDUCATOR-CERTIFICATION/ PAGE 3 OF 5
Instructions for the Educator Preparation Program (EPP) Provider
Step 1: If an Arizona Local Education Agency is seeking to place a student teacher in a paid position, verify the
following:
1. The student teacher is enrolled in the culminating student teaching capstone experience of a State Board
approved educator preparation program.
2. The student teacher has a minimum GPA of 3.0 on a 4.0 scale, or the equivalent.
3. The student teacher has passed the required Arizona Educator Professional Knowledge and Subject
Knowledge exams that correspond to the certificate the student teacher is pursuing.
4. The student teacher has been hired by a school district that has agreed to the Board approved EPP written
supervision plan regarding onsite mentorship and induction.
5. Student teachers who are placed in a special education classroom must have a Bachelor’s degree (official
transcripts posting the degree required).
Step 2: If the above requirements are met, complete Section 1: EPP Request for a Student Teaching Intern
Certificate.
Step 3: Give the completed EPP Request for a Student Teaching Intern Certificate and all other pages of this
application to the employing district or charter school.
Instructions for the District or Charter School Superintendent
Step 1: Complete Section 2: School District/Charter School Request for Issuance of a Student Teaching Intern
Certificate.
Step 2: Give the following documents to the Student Teaching Intern Certificate applicant:
The completed EPP Request for Student Teaching Intern Certificate signed by the EPP administrator.
The completed District/Charter School Request for Student Teaching Intern Certificate form.
The Application for Student Teaching Intern Certificate (to be completed by the applicant).
Instructions for the Student Teaching Intern Applicant
Step 1: Complete all sections of Section 3: Application for Student Teaching Intern Certificate.
Answer every Background Question, sign and date the application.
If you answer “Yes” to any Background questions, you must submit a completed Explanation of Incident form
for each incident, even if the incident was previously disclosed.
Step 2: Submit the following to the ADE-Certification Unit:
The completed EPP Request for a Student Teaching Intern Certificate.
The completed District/Charter School Request for a Student Teaching Intern Certificate.
The completed Application for Student Teaching Intern Certificate.
A copy of your passing score report for the required Professional Knowledge exam.
A copy of your passing score report for the required Subject Knowledge exam.
If you will be student teaching in a special education classroom, submit official transcripts posting your
Bachelor’s or more advanced degree.
A check or money order for $60. Credit card payments may be accepted for in-person applicants at the
Phoenix Certification Customer Service Counter. Certification fees are nonrefundable.
APPLICATION FOR STUDENT TEACHING INTERN CERTIFICATE
Arizona Department Of Education - Certification Unit
Mailing Address: P.O. Box 6490, Phoenix, AZ 85005-6490 • Telephone: 602.542.4367
** REQUIREMENTS MAY BE SUBJECT TO CHANGE AND ARE FULLY REFERENCED IN THE ARIZONA REVISED STATUTES AND ADMINISTRATIVE CODE. **
4/10/2017 WWW.AZED.GOV/EDUCATOR-CERTIFICATION/ PAGE 4 OF 5
SECTION 1: EPP REQUEST FOR A STUDENT TEACHING INTERN CERTIFICATE
This section must be completed by an approved representative of the Educator Preparation Program (EPP) provider.
Student Teacher Name: Social Security Number: XXX-XX- _
Educator Preparation Program Institution: _
By signing this form, I verify the following:
The above named student teacher is enrolled in the culminating student teaching capstone experience of the
following Board approved educator preparation program: .
The student teacher has a minimum GPA of 3.0 on a 4.0 scale, or the equivalent.
The district or charter school in which the student teacher has been placed has agreed to the Board approved
written supervision plan for onsite mentorship and induction that includes the following:
o The educator preparation provider’s roles and responsibilities for the Program Supervisor.
o The onsite mentorship and induction provided by the Local Education Agency (LEA).
_____________________________________________ ________________________________________
Signature of EPP Representative Title
_____________________________________________ ______________________________ ________________
Print Name Phone Number Date
SECTION 2: DISTRICT/CHARTER SCHOOL REQUEST FOR A STUDENT TEACHING INTERN CERTIFICATE
This section must be completed by the District or Charter School Superintendent.
Student Teacher Name: Social Security Number: XXX-XX- _
Name of District or Charter Holder: _
Name of School: _
By signing this form, I verify that I am requesting a Student Teaching Intern certificate for the above named student
teacher.
_____________________________________________ ________________________________________
Signature of District/Charter School Superintendent Title
_____________________________________________ ______________________________ ________________
Print Name Phone Number Date
APPLICATION FOR STUDENT TEACHING INTERN CERTIFICATE
Arizona Department Of Education - Certification Unit
Mailing Address: P.O. Box 6490, Phoenix, AZ 85005-6490 • Telephone: 602.542.4367
** REQUIREMENTS MAY BE SUBJECT TO CHANGE AND ARE FULLY REFERENCED IN THE ARIZONA REVISED STATUTES AND ADMINISTRATIVE CODE. **
4/10/2017 WWW.AZED.GOV/EDUCATOR-CERTIFICATION/ PAGE 5 OF 5
SECTION 3: PERSONAL INFORMATION
Please type or print in blue or black ink.
Social Security Number: - - Date of Birth: / / Gender: M / F
Full Legal Name: Last: First: Middle: _
Mailing Address: _
City: State: Zip: _
Contact Information: Phone: E-mail Address: _
Ethnicity: (Gender and Ethnicity are requested for federal reporting purposes only)
American Indian or Alaskan Native Asian or Pacific Islander Black or African-American (not Hispanic)
Hispanic or Latino White (Not Hispanic) Other
SECTION 4: BACKGROUND QUESTIONS
Answer every question, sign and date. ATTENTION: If “YES” is indicated for any of the following questions, please attach a full explanation
to this application; a statement must be provided with each application.
1.
YES__ NO__ Have you ever had any professional
certificate or license, revoked or suspended?
2.
YES__ NO__ Have you ever received a reprimand or other
disciplinary action involving any professional certification or
license?
3.
YES__ NO__ Are you currently under investigation or
subject to a proceeding involving any professional
certification or license?
4.
YES__ NO__ Have you ever been convicted of any felony
offense?
5.
YES__ NO__ HAVE YOU EVER BEEN ARRESTED FOR ANY OFFENSE?
6.
Have you ever been arrested for any of the following offenses in this state or similar offenses in another jurisdiction? (Answer every question below.)
YES__ NO__ Second-degree murder
YES__ NO__ Aggravated assault resulting in serious physical
injury or involving the discharge, use or threatening
exhibition of a deadly weapon or dangerous instrument
against an individual
YES__ NO__ Sexual assault
YES__ NO__ Molestation of a child
YES__ NO__ Sexual conduct with a minor
YES__ NO__ Commercial sexual exploitation of a minor
YES__ NO__ Sexual exploitation of a minor
YES__ NO__ Child abuse
YES__ NO__ Kidnapping
YES__ NO__ Sexual abuse of a minor
YES__ NO__ Taking a child for the purpose of prostitution as
prescribed in section A.R.S.§13-3206
YES__ NO__ Child prostitution as prescribed in section
ARS§13-3212
YES__ NO__ Involving or using minors in drug offenses
YES__ NO__ Continuous sexual abuse of a child
YES__ NO__ Manslaughter
YES__ NO__ Attempted first-degree murder
YES__ NO__ Any other dangerous crime against children as
defined in section A.R.S.§13-604.01
YES__ NO__ Any of the above listed offenses if committed as
a preparatory offense as described in A.R.S.§13-1001
YES__ NO__ Any offense causing you to register as a sex
offender
YES__ NO__ First-degree murder
YES__ NO__ Armed Robbery
YES__ NO__ Incest
YES__ NO__ Exploitation of minors involving drug offenses
YES__ NO__ Sexual abuse of a vulnerable adult
YES__ NO__ Sexual exploitation of a vulnerable adult
YES__ NO__ Commercial sexual exploitation of a vulnerable
adult
YES__ NO__ Abuse of a vulnerable adult
YES__ NO__ Molestation of a vulnerable adult
YES__ NO__ Neglect of a vulnerable adult
I understand that pursuant to ARS § 15-534, any person who makes a false statement, representation or certification in any application for
certification is guilty of a misdemeanor offense. I have read and understood the rules and statutes related to unprofessional and immoral conduct
including resignation from a contracted position without authorization and duties to report as required by law. I swear or affirm that the
foregoing information completed by me, or submitted by me for certification purposes is, to the best of my knowledge, true and correct.
Furthermore, should any part or all of the information herein provided prove to be false, I recognize that it shall be just cause for revocation,
suspension, or other disciplinary action against any certificate issued to me by the Arizona Department of Education or denial of my application.
___________________________________________________________ _____________
Applicant’s Signature Date
