The application form requires the applicant to furnish all of the following pertinent information necessary to determine the qualifications of the applicant for a probationary certificate:

1. (1) the date;
2. (2) name, address and telephone number where applicant can be reached;
3. (3) date of birth;
4. (4) education;
5. (5) work experience;
6. (6) certificates and other professional licenses, if any, held previously or currently;
7. (7) title of position to which appointed or promoted;
8. (8) date of appointment or promotion to position;
9. (9) governmental unit by which employed;
10. (10) duties in a new position, in sufficient detail to determine appropriate type and level of certification;
11. (11) name and title, certification, or other qualifications of persons to be responsible for supervision; and
12. (12) Social Security number.

History Note: Authority G.S. 143‑151.13;
Eff. June 28, 1979;
Amended Eff. July 18, 2002;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 9, 2018.