ࡱ> PRO#` bjbj5G5G B0W-W-  8 8 8 L 8<4L z7DJ j~ m1666666$l8h:7!8 PBFPP7 447jjjP^ 8 m1jPm1jj, 8 .8 i{j-1TJ70z7-d;Nd;4.d;8 .xjDx77 ^z7PPPPL L L DL L L L L L  FORM D - Criminal Background Information (Complete, print, sign, and date this form.) Full Name: _____ FORMTEXT      ____________________________________ Please answer the following questions: Have you ever been convicted of, or pled no contest to, a misdemeanor?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Have you ever been convicted of, or pled no contest to, a felony?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Do you currently have any criminal charges pending against you?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Have you ever had an application for a teaching credential in Michigan Or any other jurisdiction denied?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Have you ever had a teaching credential in Michigan or in any other jurisdiction suspended, denied, revoked, nullified or otherwise invalidated?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Have you ever had any professional or occupational credential, license or certificate denied, revoked or nullified?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If you answered yes to any of the above, have you disclosed this information to the School of Education, in writing, prior to the signature date below?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  N/A I declare all the answers I have given are true, correct and complete. _________________________________________________________ ___________________ Signature Date Statement of Understanding By signing below, I acknowledge that I have read and understand the following statements: As a candidate for Michigan teacher certification, I understand that the Michigan Department of Education enforces strict rules regarding the legal acceptability of candidates who wish to become certified teachers. I understand that misrepresentation or falsification of records, i.e. fraud, will almost certainly result in immediate dismissal from the Aquinas College School of Education certification program. I understand that Aquinas College is required to report to the Michigan Department of Education all certification candidates with any misdemeanor or felony convictions. I understand that I am obligated to report any change in my legal status and will contact the School of Education immediately of ANY infractions, misdemeanors or felonies that take place after the signature date below. I understand that even with recommendation for certification from Aquinas College, the final decision regarding issuance of teacher certification is made by the Michigan Department of Education. _________________________________________________________ ___________________ Signature Date     RTVtvB D y_RDh} hVM5CJOJQJh} hVMB*aJph3jh4-h5>*B*UaJmHnHphu.jh4-h4-5>*B*UaJphh4-h5>*B*aJph(jh4-h5>*B*UaJphhVMB*aJphhxB*aJphh5OJQJhhOJQJhOJQJh"3 h5h5 hSFaJh5h5aJTB D @  f @ hh^h`hgd5^gd5 & Fgd5$a$gd5gd"3"$ 2$@ P !$`'0*a$gdVM$a$gdVMgd$a$gdgdSFD   " # $ * + 9 : ; = ?  μ֯Ν֐~֐l֐bWMh5OJQJaJhuhuOJQJhuOJQJaJ#jhxhxOJQJU#j\hxhxOJQJUh5huOJQJaJ#jhxhxOJQJUh5h5OJQJaJ#jthxh>8OJQJUhxOJQJjhxOJQJUh5OJQJh5h55OJQJh"35OJQJ        5 ? M O U V d e f l m { ̺ԯ̃̕ԯyyoyoy]#jhxhxOJQJUh"3OJQJaJh5OJQJaJ#jhxhxOJQJU#j,hxhxOJQJUh5OJQJh5h5OJQJ#jhxhxOJQJUhxOJQJh5huOJQJaJjhxOJQJU#jDhxhxOJQJU#{ | }   ! 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