Fillable Printable Ia Superintendent Application For Certification 092014

Ia Superintendent Application For Certification 092014

OhioDepartmentofDevelopmentalDisabilities

County Board Certification Application

(EffectiveSeptember2014)

Instructions:(Please,readcarefully.)

1.Completeaseparateapplicationforeachcertificationrequested.Failuretothoroughlycompleteapplicationforand/orsubmit 

requiredsupportingdocumentswillresultinreturnoftheapplicationtotheapplicantbyemail.

2.SubmittheapplicationtotheOhioDepartmentofDevelopmentalDisabilities(DODD),Attn:ProviderCertificationUnitbyemail

toProvider.Ce

[email protected].Emailispreferable,butyoumayalsofaxto614‐728‐7836

.Submitcopiesof

correspondingofficialtranscripts,gradereports,verificationsofseminarcompletion,andverificationofcontinuingprofessional

development.



A.CertificationArea:(SelectonlyOneAreaandOneApplicationtype)

AreaApplicationType

InvestigativeAgent

☐LevelOne☐Initial☐Renewal

☐LevelTwo☐Initial☐Renewal

Superintendent

☐OptionOne☐Initial☐FirstRenewal☐SubsequentRenewal

☐OptionTwo☐Initial☐Renewal

EarlyIntervention

☐Specialist☐Initial,1Year☐Initial,5Year☐Renewal,1year☐Renewal,5year

☐Supervisor☐Initial,5Year☐Renewal,5Year



B.ApplicantInformation:

LastName:



FirstName:



MiddleName:



OtherNames(i.e.maidenorotherlegalnames):



DateofBirth:



SSN:



PhoneNumber:



EmailAddress:



HomeAddress:



City:



State:



Zip:



HaveyouresidedoutsideofOhiowithinthelastfive(5)years?

☐Yes*☐No

*Ifyes,ensurethatFBIreportissenttothecertificationauthoritydirectlyfromBCII.



CurrentEmployment



Employer’sName:



WorkPhone:



WorkAddress:



City:



State:



Zip:



CurrentPosition:





Education:HighestDegreeObtained(C

heckonlyOne.)

☐HighSchoolDiplomaorGED

HighSchool:



Year

Graduated:



☐AssociateDegree

College/University:



Year

Graduated:



☐BachelorDegree

☐MasterDegree

☐DoctorateDegree



OtherR

egistrations/Certifications/LicensesHeld:

TypeandIssuing

Agency/State

NameonLicense

(ifotherthannameonapplication)

LicenseNumberIssuance/Effective

Date

Expiration

Date:









C.Convictions/AdverseActions:

Haveyoueverbeenconvictedofanyfelonyormisdemeanor(otherthanaminortrafficoffense)?

Youmustanswerthisquestioneveniftherecordofyourconviction(s)hasbeensealedorexpungedbyacourtoflawand

regardlessofwhetherornottheconvictionappearsonacriminalbackgroundcheck.Ifyouanswer“Yes”,useaseparatesheet

ofpapertoprovideadetailedpersonalaccountofthenatureofth

eoffenseincludingthenameoftheconviction,thedate,the

location(i.e.city,county,andstate),andanexplanationleadingtotheconviction.Iftheconvictionhasbeensealedor

expunged,alsoprovidedetailedinformationregardingthesealingorexpungementandattachacopyofthecourtjournalentry.

☐Yes*☐No

Haveyoueverhadaregistration,certifi c ation,orlicense(excludingaDriver’sLicense)suspendedorrevoked?

(If

youanswer,“Yes”,useaseparatesheetofpapertoexplain.Includeinformationregardingtheparticular

registration/certification/licenseincludingissuingauthority.)

☐Yes☐No

*AnyBCIIand/orFBIreportsmustbesentdirectlyfromBCIIinLondon,OhiotoDODD.



D.RequiredNotice:

Iftheholderoforapplicantforcertificationand/ortheemployingCountyBoardofDDorCouncilofGovernmentbecomes

awarethattheholderoforapplicantforregistrationisguiltyofseriousintemperate,immoral,orconductunbecomingto

his/herposition,and/orisguiltyofseriousincompetenceornegligencewithinthescopeofher/hisduties,and/orhasbeen

arrested,convi

cted,orpledguiltytoanyofthefelonyormisdemeanoroffensesdescribedinAR5123:2‐2‐02,he/sheshallnotify

thecertifyingauthorityinwritingwithin72hours.



E.Applicant’sStatement:

Iherebyattest(certify)thattheinformationcontainedonthisapplicationistruetothebestofmyknowledge.Iagreeto

completethenecessaryseminars,collegecourses,and/orcontinuingprofessionaldevelopmentunitsrequiredtoreceiveinitial

certificationortorenewanexistingcertification.





SignatureofApplicantDateSigned



ReviewerOnly:

SignaturebytheDODDCertificationSpecialistisrequiredforissuanceofcertificationforSuperintendent,Early

InterventionorInvestigativeAgent.

☐Applicanthasmettherequirementsofapplicablewor kexperienceforthecertificationrequested.

☐ApplicanthassuccessfullycompletedtherequiredOr ientationProgram.

☐Applicanthasme

ttherequirementsofapplicableeducation/trainingforth

ecertificationrequested.

Iftheapplicantanswered“Yes”tothefirstquestionunderC,thereviewermustcheckoneofthefollowingboxes:

☐ApplicanthascompletedaBCIIcriminalbackgroundcheckanddoesNOThaveacriminalrecordthatprecludes

issuanceofcertification.

☐Appli

canthascompletedaBCII

criminalbackgroundcheckandhasmettherehabilitationstandards.





SignatureofCertificationAuthorityDateSigned

