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Teacher Registry System

APPLICATION FOR INTERIM PROFESSIONAL CERTIFICATION FOR TEACHING AUTHORITY FOR GRADUATES OF AN ALBERTA TEACHER PREPARATION PROGRAM
(Authorized by the Minister pursuant to the School Act, RSA 2000 Chapter S-3) Sections: 92(1), 93, 276 and the Certification of Teachers Regulation AR 3/99 as amended by AR 213/2003 Application Reference Number: 636718 Post-Secondary Student Identification Number: 1. Current Full Legal Name: Title: Miss Current Surname: Simoneau Given Name: Catherine Middle Name: Rose All Other Legal names: Row Surname Title First Middle Home Phone:
C ountry Are a Phone Num be r

4. Mailing Address: 10097283 Line 1: 379 MOUNT APEX GREEN SE Line 2: City: CALGARY Province/State: ALBERTA Country: CANADA Postal/Zip T2Z 3B8 Code:

403 8503517

2. Place of Birth If in Canada, please provide copy of Birth Certificate City: Grande Prairie Province/State: Alberta Country: Canada Date of Birth: 1983/05/17 3. Have you ever held an Alberta Teaching Certificate? _ YES X NO

Business ext. Phone: E-mail Address:

catherinesimoneau83@gmail.com

5. Immigration/Employment Status: (See Instructions regarding required evidence) Status: Born Canadian Citizen

The personal information collected as part of this application for teacher certification is collected pursuant to the provisions of the Certification of Teachers Regulation and section 33 of the Freedom of Information and Protection of Privacy Act (FOIPP Act) . This information will be used for the purpose of processing your application to determine your eligibility for Alberta teacher certification. The personal information will be treated in accordance with the FOIPP Act. Questions regarding the collection may be directed to the Registrar, Professional Standards Branch, Alberta Education, 10044 108 Street, Edmonton, Alberta T5J 5E6. Telephone: (780) 427-2045 (Dial 310-0000 to be connected toll-free from anywhere in Alberta).

6. Post-Secondary Institution(s) Attended Row 1 Name of Institution University of Calgary Language of Instruction English Was this your Alberta teacher preparation program? X YES _ NO Are you enrolled in the CTS Bridging Program? _ YES X NO Dates of Attendance Credential Earned Date Credential Earned Sep 2012 to Apr 2014 Bachelor of Education Apr 2014 https://extranetapp.learning.gov.ab.ca/trs.internet/Headerless.aspx?webapplicationID=f3759b85-cd9e-4724-b9ab-f02c58f10e16&type=ABGRAD&french=false

Location of Institution Alberta Canada

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Teacher Registry System

Sep 2012

to

Apr 2014

Bachelor of Education

Apr 2014

Journeyman Certificate or Professional Degree/Diploma Notes Specialization in secondary English Language Arts Name of Institution Mount Royal University Language of Instruction English Was this your Alberta teacher preparation program? _ YES X NO Are you enrolled in the CTS Bridging Program? Dates of Attendance Sep 2008 to Apr 2012 Credential Earned Bachelor of Arts _ YES X NO Date Credential Earned Apr 2012 Location of Institution Calgary Alberta Canada

Journeyman Certificate or Professional Degree/Diploma Notes English degree was earned with a minor in History I hereby authorize the Registrar for teacher certification of Alberta Education to contact any of the institutions that I have attended to clarify or obtain any information required for the assessment of my credentials. _____________________________ _____________________________ _____________________________ Applicant's Name (Print) 7. Self-Declaration: I declare that I have read and understood the descriptors of knowledge, skills and attributes (KSAs) related to interim professional certification as outlined in the Teaching Quality Standard Ministerial Order 016/97 and I hereby attest to my ability and commitment to apply them appropriately toward student learning. I commit to teaching practice and ongoing professional growth in keeping with the Teaching Quality Standards and descriptors of quality teaching under the Ministerial Order 016/97. _______________________________________ Applicant's Signature _______________________________________ Date Applicant's Signature Date

8. Self-Disclosure: All questions must be answered. A false declaration or omission may be grounds for the denial, suspension or cancellation of a teaching certificate. Despite your response to any of the questions below, on a random basis you may be required to provide to this office a criminal record check.

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provide to this office a criminal record check.

Teacher Registry System

A. Has your credential, certificate, permit or license to teach whether in Canada or in another country ever been denied, suspended or cancelled? _ YES X NO If yes, please complete the following: Place: Date: Details:

B. Is your certification to teach currently under investigation in another jurisdiction? _ YES X NO If yes, please complete the following: Place: Date: Details:

C. Have you ever voluntarily or involuntarily surrendered your credential, certificate, permit or license to teach in another jurisdiction? _ YES X NO If yes, please complete the following: Place: Date: Details:

D. Are you currently under investigation or charged with any offence under any statute*, whether in Canada or in another country? _ YES X NO *In Canada, any statute includes, but is not limited to the Criminal Code and the Controlled Drugs and Substances Act. If yes, please complete the following: Current Charges Row Offence Location Charge Date

8. Self-Disclosure Continued: E. Have you ever been convicted or been pardoned under the Criminal Records Act of a criminal offence under any statute* whether in Canada or in another country? _ YES X NO *In Canada, any statute includes, but is not limited to the Criminal Code and the Controlled Drugs and Substances Act. If yes, please complete the following: Have you ever been convicted or pardoned

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Have you ever been convicted or pardoned Row Offence**

Teacher Registry System

Location

Conviction Date

Pardon Date if Applicable: **For each offense listed, please provide all official Notice(s) of Conviction directly from the Clerk(s) of the Court where the conviction(s) took place. F. Have you ever been given a conditional discharge in respect to a criminal offence in Canada or in another country? _ YES X NO If YES, please provide documentation that provides evidence of the date of discharge and confirms whether the conditions of the discharge have been met. Date of Discharge:
NOTE: The presence of a record of charges or convictions does not necessarily exclude you f rom certif ication. Each case will be reviewed to determine its relevance to the requirements of the teaching prof ession on an individual basis and in accordance with the Certi f i ca ti on of Tea chers R egul a ti on.

9. Undertaking I understand that depending on the nature of my offence(s), I may be required to provide an official criminal record search document by fingerprint comparison. I understand that I am responsible for all costs involved in providing such documentation to the Professional Standards Branch of Alberta Education. I hereby undertake to provide, upon request, official police records when and as required. Authorization I hereby grant to the Registrar for teacher certification of Alberta Education full authority to conduct, at his discretion, a criminal record check or background check or enquiry from any police authority or other authority, organization or institution with regard to any criminal conviction or charge or any of the other matters referred to in Section 8. I further authorize and consent to the release of such details of convictions and outstanding charges by any law enforcement agency or authority to the Registrar for teacher certification of Alberta Education. I also consent to the release of confirmation of relevant convictions and outstanding charges to school authorities requesting such information.

DECLARATION I declare that the particulars that have been furnished on this form are true and complete in all respects and that no relevant information has been withheld. I declare that all documentation that may be submitted by me has not been changed or altered in any way. I understand that a false declaration or willful omission, or submission of altered, tampered or forged documentation may result in the non-issuance, suspension or cancellation of my teaching certificate under the Certification of Teachers Regulation. _______________________________________ Applicant's Signature _______________________________________ Date

APPLICATION CHECKLIST FOR APPLICANTS PREPARED AS TEACHERS WITHIN ALBERTA

Important - Before you mail your application, please review the following application items:
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Teacher Registry System

v Ensure you have provided your signature in sections 6, 7, and 9 on the printed application form. v If you did not pay the application fee on-line: -Enclose a cheque or money order made payable to the Alberta Minister of Finance. OR -Contact Professional Standards Branch at (780) 427-2045 to pay by credit card. v Enclose or arrange to provide acceptable evidence* of all names used for legal purposes. v Enclose or arrange to provide acceptable evidence* of your immigration/ employment status in Canada. v Enclose or arrange to provide a photocopy of your birth certificate, if your place of birth is Canada. Mailing address Professional Standards Branch 10044 108 Street Edmonton, AB T5J 5E6 In Person 2nd Floor 44 Capital Boulevard 10044 108 Street Edmonton, AB

NOTE: All information entered on this form becomes part of your permanent record with Alberta Education. Failure to complete all requested information may result in your application for teacher certification being returned to you unprocessed. If you omitted any information or need to include additional information, please attach an additional page(s) and ensure you have dated and signed each page. Teacher Certification Application Fee (Application Fees Are Non Refundable) $200.00

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