The undersigned attests that the documentation required by the Professional Certification office is on file. Also, the undersigned certifies under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct:

Institution/organization: The Evergreen State College	Code: 50027	Telephone Number: 360.867.6559

Signature: Maggie Foran	Date: 6/15/12

Organization Program Director/Dean/Director of Education/Certification Officer or Designee

List Names in Alphabetical Order

Complete Legal Name – Last, First Middle and Address	Birthdate	Washington Certificate Number	WSP/FBI Clearance Received*	Applied after 9/30/11 Y/N	Endorsements** Area Type	OSPI Use Only