Graduate Admissions Application Full Name: * First and Last Name Program: * Last 4 SSN digits: * The School of Education at Piedmont College and The Georgia Professional Standards Commission believe that teachers should be held to the highest moral standards and code of ethics. The School of Education maintains the right to deny admission to the program for good cause, after an investigation is held and a notice and hearing are provided to the applicant. Any one of the following may be considered good cause for denial of admission.

Enter a truthful "Yes" or "No" response to each of the following questions. All questions must have a response. DO NOT include matters that the PSC has investigated or is currently investigating.

Personal Affirmation 1. Have you ever had an adverse action (i.e. warning, reprimand, suspension, revocation, denial, voluntary surrender, disbarment) taken against a professional certificate, license or permit issued by an agency OTHER THAN the Georgia Professional Standards Commission? 2. Are you currently the subject of an investigation involving a violation of a profession’s laws, rules, standards or Code of Ethics by an agency OTHER THAN the Georgia Professional Standards Commission? 3. Have you ever received a less than honorable discharge from any branch of the armed services? 4. Have you ever left an employment position (retired, resigned, been dismissed, terminated, non-renewed or otherwise) while under investigation? 5. Are you currently the subject of an investigation involving sexual misconduct or physical harm to a child? 6. Are you the subject of a pending investigation involving a criminal act? 7. For any felony or any crime involving moral turpitude, have you ever: 1. Pled guilty;
2. Entered a plea of nolo contendere;
3. Been found guilty;
4. Pled guilty to a lesser offense;
5. Been granted first offender treatment without adjudication of guilt;
6. Participated in a pre-trial diversion program;
7. Been found not guilty by reason of insanity; or
8. Been placed under a court order whereby an adjudication or sentence was withheld

8. Have you ever been convicted, or pled to a lesser offense for any sexual offense? 9. Have you been convicted of a drug offense felony or misdemeanor) after July 1, 2008, while holding any professional certificate, license or permit? I affirm that there is nothing in my personal history that would prevent me from being qualified for the teaching profession. I understand that upon employment in a Georgia school a complete background check will be run, including a fingerprint check. I also understand that my electronic signature is as binding as a written signature. Signature: * Date: * Email: *