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Thank you for your interest in the Olympic College CTE Teacher Certification Program. Step 1. Please fill out the CTE Teacher Certification Program Registration Form.Step 2. If you do not wish to disclose your Social Security Number on the CTE Teacher Certification Program Registration Form,you are required to fill out the “Request for Student’s Taxpayer Identification Number” form. When doing so please fill out Part 1 and Part 3 in their entirety while marking the appropriate box in Part 3 This form also requires your hand written signature. Step 3. This package is made to be filled out electronically. After doing so, save the document as your name and then attach it to an email. The package is also designed to be printed in a five page format to either scan(and email) or fax. Once you have completed the forms package in its entirety, send it via your preferred method: via email to: [email protected], or via secure fax to: 360.473.2830 or via post to: CTE Teacher Certification Program CSC 421 1600 Chester Ave Bremerton WA., 98337-1699 If you have any questions or concerns that apply to this process, please email: [email protected] CTE Teacher Certification Program Registration Package

CTE Teacher Certification Program Registration Package · Please fill out the “CTE Teacher Certification Program Registration ... on the “CTE Teacher Certification Program Registration

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Page 1: CTE Teacher Certification Program Registration Package · Please fill out the “CTE Teacher Certification Program Registration ... on the “CTE Teacher Certification Program Registration

Thank you for your interest in the Olympic College CTE

Teacher Certification Program.

Step 1. Please fill out the “CTE Teacher Certification Program Registration Form.”

Step 2. If you do not wish to disclose your Social Security Number on the “CTE Teacher Certification Program Registration Form,” you are required to fill out the “Request for Student’s

Taxpayer Identification Number” form. When doing so please fill out Part 1 and Part 3 in their

entirety while marking the appropriate box in Part 3 This form also requires your hand written

signature.

Step 3. This package is made to be filled out electronically. After doing so, save the document as your name and then attach it to an email. The package is also designed to be printed in a five page format to either scan(and email) or fax. Once you have completed the forms package in its entirety, send it via your preferred method:

via email to: [email protected],

or

via secure fax to: 360.473.2830

or

via post to: CTE Teacher Certification Program

CSC 421

1600 Chester Ave

Bremerton WA., 98337-1699

If you have any questions or concerns that apply to this process, please email:

[email protected]

CTE Teacher Certification Program

Registration Package

Page 2: CTE Teacher Certification Program Registration Package · Please fill out the “CTE Teacher Certification Program Registration ... on the “CTE Teacher Certification Program Registration

First Name

Zip Code

Last Name Address City Day telephone

State

Are you the first generation in your family to go to college? Yes No

Which race do you consider yourself to be? (This question is optional. The information is used for statistical purposes only.)

American Indian or Alaska Native (597) What is the name of your enrolled or principal tribe:Black or African American (872) Chinese (605) Filipino (608) Japanese (611) Korean (612) Native Hawaiian or Pacific Islander (653) Vietnamese (619) White (800) Other Asian (621) Other Pacific Islander (681) Other Race (799) Specify:

Are you of Spanish or Hispanic origin? No (999) Mexican, Mexican American, Chicano (722) Cuban (709) Other Spanish/Hispanic/Latino Specify:

Is English your first language? Yes No

Are you a US Citizen? Yes No If not, country of citizenship.

********************

Your intended Area of Career Technical Education K-12 Study: Agriculture Business & Marketing Health Science Human Services

Skills and Technology Sciences Work Site Learning Career Choices Specialty Area – Choose from V Codes on OSPI website or page three of this form – As you earn your certificatethrough the Business and Industry route, you may only teach the specific subcategory indicated on the certificate – which is based on your occupational experience.

Do you hold a Washington teacher, administrator, educational staff associate or CTE Certificate? Yes No Certificate Number

Do you have a Bachelor’s degree? Yes No If so, from what College/University? Date

Do you hold a Master’s degree? Yes No If so, from what College/University? Date

Do you hold industry certifications? Yes No If so, please identify._

For the Business and Industry Route, you must be able to identify three years (6,000 hours) of paid occupational experience in the subcategory specialty CTE

field. One year (2,000 hours*) must have been completed within the past six years. *If all or part of the 2,000 hours is more than six years old, an additional 300 hours of recent occupational experience (occurring in the last two years) is required. Applicants using a certificate plus 3 years of teaching experience in lieu of a

program must verify the same amount of paid occupational experience. Page 2 of the Application for a Washington State CTE certificate must be completed and attached to this enrollment form. Current CTE teachers do not need to submit documentation of paid occupational experience with this enrollment form because it has been submitted with their certification documents.

I certify to the best of my knowledge all statements on this form are true. Admission to OC carries with it the expectation that students agree to comply with established OC policies and regulations. If submitting electronically, your typed signature below indicates acceptance of the previous two sentences.

Print Name Signature Date

Enrollment Form 20171017

E mail

Social Security Number - - Your social security number is confidential and, under federal law

called the Family Educational Rights & Privacy Act, the College will protect it from unauthorized use and/or disclosure. In compliance with state/federal requirements, disclosure may be authorized for the purposes of state and federal financial aid, Hope/Lifetime Learning tax credits, academic transcripts, or accountability research. A College ID number will be assigned for use in all future College transactions other than those listed above.

Date of Birth (MM/DD/YYYY) Gender Identity

Page 1 of 3

CTE Teacher Certification Program Registration Form

Evening telephone

Page 3: CTE Teacher Certification Program Registration Package · Please fill out the “CTE Teacher Certification Program Registration ... on the “CTE Teacher Certification Program Registration

Page 2 of 3

Verification of paid occupational experience in the specific career and technical education certificated field is required. Listedemployment must be verified by letter from the employer or by tax returns. Self-employment must be verified by submitting a copy ofyour business license, tax return, or letters from clients.

Occupation

Dates of Employment

Duties

Total Number of Paid Hours

Employer

Address

Telephone Number

City State Zip Code

Occupation

Dates of Employment

Duties

Total Number of Paid Hours

Employer

Address

Telephone Number

City State Zip Code

Occupation

Dates of Employment

Duties

Total Number of Paid Hours

Employer

Address

Telephone Number

City State Zip Code

Occupation

Dates of Employment

Duties

Total Number of Paid Hours

Employer

Address

Telephone Number

City State Zip Code

Total Number of Paid Hours for All Listed Employers

Verification of Paid Occupational Experience

Item Number Course ID Item Number Course ID Item Number Course ID

1. Select the desired quarter you wish to start

2. Select "Continuing Education" for "Include Classes"

3. Select the "CTE Teacher Certification" button

4. Find the "Item" number and ID of the class for your first enrollment(s) and record them below

To find your first class for enrollment, go to: https://apps.olympic.edu/classschedule/Default.aspx

Cla

ss E

nrol

lmen

t

Page 4: CTE Teacher Certification Program Registration Package · Please fill out the “CTE Teacher Certification Program Registration ... on the “CTE Teacher Certification Program Registration

The following specialties area certificates are based on completion of the Business and Industry Route:

AGRICULTURE

Subcategory Specialty Areas for Agriculture Education

V010101 Agribusiness V010603 Floriculture

V010201 Agricultural Mechanics V011001 Agriculture Food Science

V010300 Agricultural Production V030101 Natural Resources

V010303 Aquaculture V410301 Chemical Technology

V010601 Horticulture V510808 Veterinarian Assistant

BUSINESS AND MARKETING

V091001 Publishing V520895 Banking Support Services

V520100 Business Management V521206 Computer Applications & Related Programs

V520300 Accounting and Related Programs V080301 Entrepreneurship

V520403 Legal Administrative Services V080706 General Sales Operations

V520404 Medical Administrative Services V520902 Lodging Management

V080102 Fashion Merchandising V521401 Marketing Management

WORK SITE LEARNING CAREER CHOICES

V600097 Worksite Learning (Must also hold a CTE Teaching Certificate)

V600092 Career Choices (Must also be certificated for Worksite Learning)

HEALTH SCIENCE

V510700 Health Infomatic Careers V510601 Dental Assisting

V510710 Health Support Services Careers V510709 Sports Medicine

V510800 Health Therapeutic Careers V511614 Nursing Assisting

V510900 Health Diagnostic Careers V260102 Biomedical Science

V261202 Health Science Biotechnology

HUMAN SERVICES

V120403 Cosmetology V190708 Early Childhood Education and Services

V120505 Food Production and Services V190901 Textiles and Apparel

V160103 Translation and Interpretation V200206 Educational Para Pro

V190403 Consumer Services V200212 Careers in Education

V190504 Food Science Dietetics and Nutrition V200493 Culinary Arts

V190601 Housing, Interiors and Furnishings V310101 Hospitality, Recreation and Tourism

V190707 Family and Community Services V510205 Sign Language Interpreter

SKILLS AND TECHNOLOGY SCIENCES

V100100 Communication Technologies V470110 Computer Technology

V143501 Engineering V470201 Refrigeration/Air-Conditioning/Heating

V141801 Material Engineering V470600 Automotive Technology

V150100 Manufacturing Technology V470603 Auto Body Repair

V280300 JROTC V470608 Aircraft Technician

V430100 Criminal Protective Services V480101 Drafting

V430106 Forensic Technology V480500 Precision Metal Worker

V430203 Fire Service V490100 Aviation Occupations

V460200 Construction Trades V490300 Water Transportation/Worker

V460302 Electrician V500400 Commercial Design/Applied Art

V460401 Building Maintenance Technician V500502 Stage Design Technician

V470101 Electrical and Electronic Equipment Repair V141000 STEM Technology

V470201 Refrigeration/Air-Conditioning/Heating

Page 3 of 3

Page 5: CTE Teacher Certification Program Registration Package · Please fill out the “CTE Teacher Certification Program Registration ... on the “CTE Teacher Certification Program Registration

Request for Student’s Taxpayer Identification Number (Substitute Form W-9S)

Return completed signed form, in person or by mail, to: Registration and Records

1600 Chester Avenue, Bremerton WA 98337

Do not submit this form to the IRS.

Complete the form in blue or black ink.

Part 1

Last Name

Taxpayer Identification Number (SSN or ITIN)

Street Address

First Name

City State

OC Student Identification Number

M.I.

Zip Code

Part 2

By my signature below, I certify that the number shown on this form is my correct SSN/taxpayer ID number.

Signature Date

~~~ OR ~~~

I am a foreign national, nonresident alien, or International student and do not have a Social Security number or Individual taxpayer ID number. I do not plan to file an income

tax return in the U.S.

I am unable to, or choose not to provide my SSN/ITIN to Olympic College at this time. I understand that I may be subject to an IRS fine for failure to do so. I further under

stand that the IRS will not be able to use the Form 1098-T filed by Olympic College to confirm my eligibility for certain education tax benefits without my SSN/ITIN.

Part 3

Signature Date

Instructions

Purpose: Olympic College must get your correct identifying number to file the Form 1098-T, Tuition Statement, with the IRS and to furnish a statement to you. This will be your social Security number (SSN) or your individual taxpayer identification number (ITIN). Form 1098-T contains information about qualified tuition and related expenses to help determine whether you, or the per-son who can claim you as a dependent , may take either the tuition and fees deduction or claim an education credit to reduce fed-eral income tax. For more information, see IRS Pub. 970, Tax Benefits for Higher Education. Under Federal law, you are required to provide the requested information.

Part 1. Enter your name and mailing address. The name should match that used by the Social Security Administration or Internal Revenue Service. Taxpayer identification number - Enter your SSN or ITIN. Please include your OC student ID number.

Part 2. Sign your name in the space provided to confirm the information provided. The registrar cannot change your records without your signature.

Part 3. Please fill out this part only if you choose not to or are unable to provide the SSN/ITIN. Check either the first or the second box and sign the statement. By law, Olympic College must ask you at least once a year for your taxpayer identification number in order to meet its obligation to file Form 1098-T.

Deliver, or mail the completed form using the enclosed postage paid, self-addressed envelope to Registration and Records. Please do not email the form. Email is not a secure way to transmit personal information. Forms also cannot be accepted via fax.

Misuse of SSNs. If Olympic College discloses or uses your SSN/ITIN in violation of Federal law, Olympic College may be subject to civil and crimi-

nal penalties.

Privacy Act Notice: Section 6109 of the Internal Revenue code requires you to give your correct SSN or ITIN to persons who must file infor-

mation returns with the IRS to report certain information. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return. The IRS may also provide this information to the Department of Justice for civil and criminal litigation and to cities and states to carry out their tax laws.