Florida Department of Education

Bureau of Educator Certification

  

Room 201, Turlington Building

  

325 West Gaines Street

  

Tallahassee, FL 32399-0400 District Number

Communication Number

 

  

  

  

  

C

H A R

8 1 3

 

  

Natural Disaster Extension/Fee Waiver

Applicant’s Personal Information

Social Security Number

First Name

 

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

 

Middle Name

Last Name

 

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

  

 

 

 

Special Extension/Duplicate Certificate Request Form

Extraordinary, Extenuating Circumstances

Relating to Hurricane Charley August 13, 2004

 

The educator identified above is an employee in a Florida public school in my district and has experienced extreme

loss of property or personal hardship resulting from the natural disaster of Hurricane Charley.

 

Due to these extraordinary, extenuating circumstances, the educator is unable to complete certification

requirements within the time line required by law. Therefore, I am requesting one of the following certificate

extensions be granted.

 

Please check appropriate box below:

 

Two-year extension to a valid three-year Temporary Certificate, expiring June 30, 2005, pursuant to Section

1012.56(6)(c), Florida Statutes. (CG -10 Form required:

$56 fee waived

) This option may be used in

combination with an extension to the Mastery of General Knowledge time line.

 

One-year extension to a valid Professional Certificate expiring June 30, 2005, pursuant to Section

1012.585(2((d), Florida Statutes. (CG -10 Form required:

$56 fee waived

)

 

  

Reissuance of a two-year Temporary Certificate expiring June 30, 2004, or June 30, 2005, pursuant to Section

1012.56(14), Florida Statutes and law in effect at initial certification, Section 231.17(6), Florida

Statutes (1999). (CG-10 Form required:

$56 fee waived

)

 

 

The educator’s certificate is lost or destroyed as a result of the hurricane. Therefore, I am requesting issuance of a

duplicate certificate (please check box).

 

Duplicate certificate, pursuant to Section 1012.56(14), Florida Statutes.

(CG-10 Form required:

$20 fee waived

)

 

 

 

 

_____________________________________________________ ______________________________

Signature of Superintendent or Designee Date