Disclosure and Affirmation Form

Name(Required)

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Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

Email(Required)

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Have you ever been convicted of a misdemeanor or felony or admitted responsibility for civil infraction or ordinance violations?(Required)

Applicants to the graduate programs in the School of Education are required to provide information about all convictions, civil infractions, and ordinance violations. An applicant to a graduate program who has been convicted of a misdemeanor or felony may be denied admission. If a student is convicted of a crime during his or her graduate program and it is the decision of the student’s department to dismiss, the student may appeal the decision to a College-level Hearing Board.

Yes

No

Have you passed the Georgia Ethics Exam or (for out-of-state educators), the equivalent required ethics verification?(Required)

Yes

No

Do you have tort liability insurance? If you are a member of PAGE or GAE this is included with your membership.(Required)

Yes

No

Comments(Required)

Please let us know what's on your mind. Have a question for us? Ask away.

Signature(Required)

I certify that the answers provided are complete and accurate to the best of my knowledge. Falsification, misrepresentation, or omission of information may result in denial of admission or subsequent removal from a graduate program in the School of Education.

Disclosure and Affirmation Form

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