Neb. Admin. Code PROFESSIONAL PRACTICES COMMISSION, tit. 95, ch. 2, app A
BEFORE THE NEBRASKA PROFESSIONAL PRACTICES COMMISSION STATE OF NEBRASKA
IN THE MATTER OF THE)
REINSTATEMENT OF:) Case No. ___(leave blank)___
)
) PETITION FOR REINSTATEMENT
)
(Name of Petitioner))
_________________________________)
(Address))
)
)
The undersigned Petitioner for reinstatement of a revoked Nebraska teaching, administrative and supervisory, or special services counseling public school certificate alleges:
1. (Set forth the type, rank, level, endorsements, and expiration dates of the certificate(s) revoked by the State Board of Education and your social security number.)
2. (Set forth the Final Decision of the Nebraska State Board of Education revoking The certificate(s).)
3. (Set forth the name(s), address(es), phone number(s), and date(s) of employment for all employers of Petitioner during the period of certificate revocation. If unemployed for over three months during any time period, set forth your activities during that time period.)
4. (Set forth the name(s), address(es), and phone number(s) of all witnesses, including yourself, that will testify on your behalf at the hearing.)
5. Petitioner has fully complied with the Order of Revocation, that he or she will not in the future engage in any practice which is listed in the statutes as grounds for revocation or suspension of a certificate, and that he or she is familiar with The criteria of professional practices adopted pursuant to 79-868.
Applicant affirms the statements in this Petition are true, correct, and complete to the best of his or her knowledge and belief.
Dated this___________ Day of ___________, 19 _____.
_____________________________
(Signature of Petitioner)
(typed name, address, & telephone number)
VERIFICATION
State of Nebraska)
)
County of___________)
I, ________________, being first duly sworn under oath, disposes and says that I am the Petitioner named in the foregoing Petition, that I have read it, know the contents therein, and that the facts therein contained are accurate and complete to the best of my knowledge and belief.
________________________
(Signature of Petitioner)
Subscribed and sworn before me this___________ day of ________________, 19 _______.
__________________________________
Notary Public
CERTIFICATE OF SERVICE
I certify that a copy of the foregoing Petition was served upon the Commissioner of Education, by certified mail, return receipt requested at the following address; 301 Centennial Mall South, P.O. Box 94987, Lincoln, NE 68509-4987
Dated this__________ day of ________________, 19 _____.
_________________________________
(Signature of Respondent)
Neb. Admin. Code PROFESSIONAL PRACTICES COMMISSION, tit. 95, ch. 2, app A