‘The University of the State of New York THE STATE EDUCATION DEPARTMENT CERTIFICATION OF COMPLETION ‘TRAINING IN SCHOOL VIOLENCE PREVENTION AND INTERVENTION PART A | TRAINEE INFORMATION “This frm ic all that you need a proc that you have completed your aandsted training For all profeioas which involve working ia school. your certificate wil be sea leckouically to te State and abould tppate on your TEACH acconnt vata a week The form ie oct one reqpirement for cericton. Other requiemeats include the application. uanscripts, ingesting. and in some cases, passing exams, For an applestion and fiber details on certification, call I (S18) 474.3001 or vit the New York State Edvestion Depantnent at wirwayied go | Pint mame exclly as Heaneatly sppea oa New Vouk Sete Eivcaton Departmen! Recads Last Naa: Ward uct Name: werey ‘Médde Nessa [M ‘Crgsriznice: | Neale GH | Peat your ee Sueet SRE Fart one Cay Ste Fockwood Orta Conai Canada [Zip Code NOHO S| Dee of Be eae Soul Seco Neater | TESA “Trainees Signature: Dae: PART “CERTIFICATION BY APPROVED TRAINING PROVIDER 1 | Provider mame complete Pan. 2. | The EDUCATION DEPARTMENT - ORIGINAL COPY aid TRAINEE COPY shoold te renamed tothe taniave witha 21 calender days of the completion of cousewoik snd wining. 3. | The provider of te comsework or taining anst tain the PROVIDER COPY. Ths copy aut be wetaned ‘nthe provider's files for aot less than six years om the date the course was completed, “Pursuant to Chapter 181 ofthe Laws of 2000, | cay thatthe pero indicoted ia Bit A has completed the reid coursenork: cr taining ia School Violence Prevention and Taervention Rane offal Ge Of “ppc Per Nene EMILY MENT GENUS GENUS OF NINE Signi of Antena Cong Ofer deaicaina Name: 7 3080 Bg Was as Cao Tela “pao Cenmeate#: 217115