Form F-12 Original Request for Instructional and Professional Lecturer Certification - North Carolina

Form F-12 is a North Carolina Department of Justice form also known as the "Original Request For Instructional And Professional Lecturer Certification". The latest edition of the form was released in December 1, 2016 and is available for digital filing.

Download a PDF version of the Form F-12 down below or find it on North Carolina Department of Justice Forms website.

ADVERTISEMENT
CRIMINAL JUSTICE EDUCATION AND TRAINING STANDARDS COMMISSION
CRIMINAL JUSTICE STANDARDS DIVISION
Post Office Drawer 149, Raleigh, NC 27602
Telephone: (919) 661-5980
Fax: (919) 779-8210
Form F-12
(Rev. 12/16)
Original Request for Instructional and Professional Lecturer Certification
Application for Probationary General Instructor Certification and Specialized Instructor Certification(s) Must Be Made Within Sixty (60)
Days From Passing the State Exam.
1.
Please type or print clearly. Attach additional sheets if necessary.
2.
This form is to be completed by the applicant, signed by the school director or ITC, and submitted to the Commission at address listed above.
3.
Education and Instructor Training Course must be supported by copies of official transcripts, diplomas, or other verifying documents attached to
this application.
For Staff Use Only:
Years:
_________________
Education:
___________________________
Name: __________________________________________________________________________________________
First
Middle
Last
Mailing Address: __________________________________________________________________________________
(Street or PO Box
City
State
Zip Code
County
Phone: ____________________ Email Address: ________________________________________________________
(Required)
Date of Birth: ____________ Age: ____ Last 4 Digits SSN: ________
(MM/DD/YYYY)
Current Agency/Firm: _______________________________________________ Business Phone: _________________
(Or mark retired or other)
Address: __________________________________________________________________________________________
Street, City, State, Zip Code
Rank or Title: _____________________________ Assignment/Position: ______________________________________
Please Check Applicable Box:
Probationary Instructor Certification
Specialized Instructor Certification
1.______________________________ 2. ____________________________ 3. ________________________________
Professional Lecturer Certification:
Law
Medicine
Psychology
Proof of CPR Certification Attached?
Yes
No
*Current CPR certification is required for all specialized certifications*
Driving History Attached?
Yes
No
*Required for Specialized Driver Instructor Certification
Practical Experience as a Criminal Justice Officer or as an employee of a Criminal Justice agency
Agency and Unit Assignment
Dates of Employment
Title or Position
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
CRIMINAL JUSTICE EDUCATION AND TRAINING STANDARDS COMMISSION
CRIMINAL JUSTICE STANDARDS DIVISION
Post Office Drawer 149, Raleigh, NC 27602
Telephone: (919) 661-5980
Fax: (919) 779-8210
Form F-12
(Rev. 12/16)
Original Request for Instructional and Professional Lecturer Certification
Application for Probationary General Instructor Certification and Specialized Instructor Certification(s) Must Be Made Within Sixty (60)
Days From Passing the State Exam.
1.
Please type or print clearly. Attach additional sheets if necessary.
2.
This form is to be completed by the applicant, signed by the school director or ITC, and submitted to the Commission at address listed above.
3.
Education and Instructor Training Course must be supported by copies of official transcripts, diplomas, or other verifying documents attached to
this application.
For Staff Use Only:
Years:
_________________
Education:
___________________________
Name: __________________________________________________________________________________________
First
Middle
Last
Mailing Address: __________________________________________________________________________________
(Street or PO Box
City
State
Zip Code
County
Phone: ____________________ Email Address: ________________________________________________________
(Required)
Date of Birth: ____________ Age: ____ Last 4 Digits SSN: ________
(MM/DD/YYYY)
Current Agency/Firm: _______________________________________________ Business Phone: _________________
(Or mark retired or other)
Address: __________________________________________________________________________________________
Street, City, State, Zip Code
Rank or Title: _____________________________ Assignment/Position: ______________________________________
Please Check Applicable Box:
Probationary Instructor Certification
Specialized Instructor Certification
1.______________________________ 2. ____________________________ 3. ________________________________
Professional Lecturer Certification:
Law
Medicine
Psychology
Proof of CPR Certification Attached?
Yes
No
*Current CPR certification is required for all specialized certifications*
Driving History Attached?
Yes
No
*Required for Specialized Driver Instructor Certification
Practical Experience as a Criminal Justice Officer or as an employee of a Criminal Justice agency
Agency and Unit Assignment
Dates of Employment
Title or Position
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Commission Accredited General and/or Specific Instructor Training (or equivalent instructor training)
School Name
Course Title
Course Length (Hours)
Date Completed
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Education
High School
Dates Attended
Diploma: Yes No
________________________________________________________________________
________________________________________________________________________
Community or Junior College
Dates Attended
Degree/Hours
__________________________________________________________________________________________________
__________________________________________________________________________________________________
University or College
Dates Attended
Degree/Hours
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Attestation
I certify that the information contained in this application is true and correct to the best of my knowledge. I acknowledge
that any omission, falsification or misrepresentation of the information provided above may result in certification being
denied, suspended, or revoked by the commission.
_____________________________________________
_______________________
Signature of Applicant
Date
Recommendation
It is recommended that the certificate requested be awarded. To the best of my knowledge and belief the applicant is of
good moral character and has the desire and the ability to provide effective instruction for criminal justice personnel.
_______________________________________
_________________________________________
Printed Name Certified School Director or
Date
In-Service Training Coordinator
_______________________________________
_________________________________________
Signature of Certified School Director or
Name of Accredited School or Agency
In-Service Training Coordinator
Phone number
Email Address
_________________________________
_______________________________________________
Form F-12 (Rev. 12/16)

Download Form F-12 Original Request for Instructional and Professional Lecturer Certification - North Carolina

673 times
Rate
4.5(4.5 / 5) 33 votes
ADVERTISEMENT
Page of 2