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CERTIFICATION RECORD FORM 9/7/2011CERT NO: 483908JNAME: MARGO ELIZABETH KINNEBERGPREVIOUS NAME:

DOB: 12/19/1988SEX;- F

CERTIFICATE TYPE: CONDITIONAL CERTIFICATEISSUE DATE: 09/07/2011

EXPIRATION DATE: 06/30/2013ENDORSEMENTS: MATHEMATICSSCIENCE

FOR USE IN: FEDERAL WAYRECOMMENDED AGENCY: SPI. OFFICE OF PROFESSIONAL CERTIFICATION1ST ISSUE

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F~eGe ipt 1~ '!: ~_ . _F FI CE O F S UP ER IN TE ND EN T O F P UB LIC IN ST RU CT IO NPrclesslcoat Cani~c3UonO LD C AP IT OL B UIL DIN G, P O BOX 472110OLYMPIA WA~a5n4-7200(360) 7536773 TDO (360) 6643829

Web Site: htlp:llwww.k12.w.a.us/certilicalicolE -M ai l: c G 'r l@ 1 \ 12 .w a .u E iAPPLICATION FOR WASHINGTON STATE

CONDITIONAL CERTIF[CA TEPlease complete the following questions and sign the affidavit.--~-------------------,~----------~~~RHlLAST fiRST MIDDLE MAIDENIFORM!'f\ N f A M Er-__f ( ~ I ' ~ n ~ n _ e = - ~ b ~ ~ ~ y ~ g ~_ ~~~~f.~~~O=-_~E~I~le~~_b~e+~~~/,

I~ I U i i i . J . - ' A . . , Ii1. NAME

2. ADDRESSill3d 3. DATE OF BIRTH( : ) e . G . 1 < : 1. - .. . . -n",:,~ ___.

4 . SOCIAL S EC UR IT Y N O. ~OPTIOflAL)(e:; 1 / 05. TELEPHONE: 6 . E-MAil

BUS INESS ( HOME Q

7. Have you ever held a Washington teacher, administ rator, or educational staff associate certificate?If yes, what was your certificate numbe .

7_ 0YES ~ NO8. Have you held an educational certificate in another slate? if yes list all such states here and complete 8. 0YES Q S J NOro,," SPlICERHD20C. I . _ I

9_ Complete the following information on your noneducational employment history for the past ten years.Employwor DiS-lncl Da[es of Emplo,(ml;l : l l lV. -A ! :6 (/ \Y" CDII e . . 0 0'1 - ~

Telephcna No,O i l . . , . 7 Sd) I . . - q d.f4ATrACH ADDITIONAL SHEETS IF NECESSARY

For use by proie~sionaIG~riifitai:ion only315IDy pe o f C e rt. Is su ed

i\Ppro~ 51:>Ulc - rio l3- sonl :17C}-fD

FORM SPIICERT 4025A (Rev. 11110) Page 1

ON

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10. list the name of every communHy college, undergraduate, and graduate institution you have attended in the space below andprovide the additional information requested.

Local /on Da l es A t la n d ed O E ! : g r e e s P Qs l BA C r eF j il s E a rn tt d~ns.l l luUQn C;,yISlale From To Granted Semeste- QU~f1i::lrI~~~J''' C O I l t r - ' ) e . . . . rDl)t)VI\

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Yes No0 1 S ( ) 10.D ~ 11.

Have you over been disc ipl ined by a past or present employer because of al legation:;; of misconduct?Are you currently or have you ever been the subject of any investigation or inquiry by an employer because ofallegatlons of misconduct?

If you answer "yes" to any of the questions 1- 5 (Section 111) ,please provide the following:A . On a separate sheet of paper state the following:a. A detailed statement including what occurred, the nature of the offense, charge or warrantb. The name and address ofthe arresting agency.c. If a court was involved, the name and address of the court.d. The date of the arrest.e. The final disposition, if any.

B . If a court WaS involved, provide a copy of the court docket (can be obtained at the court in which the chargers] were filed).C. Provide a copy of the complete arresting officer's report.D. If a court was involved, provide the sentence and judgment {can be obtained at the court in which the chargers} were f iled).E. Ifthe arrest was driving related, provide a copy of a current and complete 5-year driving abstract.NOTE; For questions 1. 2, 3, DO NOT include minor in possession (MIP)fminor in consumption (MIC) occurring more than 2 yearsago or driving under influence (DUll occurrinq more than 5 years ago.Yes NoF9 ~1.I ,j ~I

0 g r 2.0 ~ 3.[Jo

~O < t 5.

In the last 10 years, have you ever been arrested for any crime or violation of the law? (Do NOT inclUde Minor inPossession [MIP]/Minor in Consumption [MIC] occurring more than 2 years ago or Driving Under Inf luence[DUI/OWI] occurring more than 5 years ago.) (Note: For "yes" responses to 1.2. 3, even if your case wasdismissed or your record was sealed you must answer this question in the affirmative.) You need not list traf ficviolations for which a fine or forfeiture of less than $30D was imposed.In the last 10years, have you ever been fingerprinted as a result of any arrest for any crime or violat ion of the law?In the last 10 years, have you ever been convicted of any crime or violation of any law? {Note: For the purpose ofthis question "convicted" includes (11 all instances in which a . plea of gui lty or nolo contendere is the basis ofconviction, [2J al l proceedings in which a sentence has been suspended or deferred, [3) Of bail forfeiture.) Youneed not list traff iC violations or fines for which a fine or forfei ture of less than $300 was imposed.

4. Have you ever been convicted of any felony crime?Do you currently have any outstanding criminal charges or warrants of arrest pending against you? This wouldinclude Washington State, any other s late, province, terri tory, andlor country.Have you ever been or are YOll presently under investigat ion in any jur isdict ion for possible criminal charges? Ifyour answer" is "yes," identify agency and location (street address, city, state) and the circumstances or detai lsrelat ing to the invest igation on a separate piece of paper.

SECTION IV. FITNESS' ,. ..' '. ,.' .'-:e . " '. _ ~ , : . . , . ' ' . . ' . : . . ~ ': ' . . ' : : ' . . ' . . ' .

DIf you answer "yes" to any question (Section I V } , provide a written explanation on a separate sheet of paper:Yes NoD ~ 1.D gj 2.0 ~ 3.U ~ 4.0 ~ 5.

Have you ever exhibited any behavior or conduct which might neqatively impact your abi lity to serve in a Tole whichrequires a certlflcate, credential, or license?In the past 10 years, have you ever enqaqed in any conduct which resulted in the damage or destruction ofproperty? (For purposes of questions 2 and 3, property includes both real and personal property owned by you oranother. Do not l is t damages done as the result of an automobile accident.]ln the last 10 years, have you ever threatened to damage or destroy property?Have you ever engaged in any conduct which resulted in the physical injury or harm of any person(sJ? (Do not listinjury or harm caused as the result of duties performed due to a job assignment such as police officer, armedforces member, or athiete.)Have you ever threatened to do physical injury or harm to any person{s)? (Do not list threats issued as the result ofduties performed due to a job assignment such as pol ice officer. armed forces member, or athlete.}

Page 2 of 4ORM SPI/CERT 40208 (Rev. 6/1 0)

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ALL APPUCANTS MUST COMPLETE rHE AFFIDAVIT

I, M O l . r~Q G.. k;nn~. certi fy (or declare) under the penalty of perjury under the laws o r the state ofWashington that the foregoing and al l infor ation included In the application IS true and correct.If the information provided or answer(s) to any question on the application or character and fitness supplement changes prior to mybeing granted certification, I must immediately notify the Offi(; of Professional Practices and my college/univers ity i f I am acollege/university candidate.Iunderstand Imust answer this applicat ion truthful ly and completely. Any falsificat ion or del iberate misrepresentat ion, includingomission of a material fact, in completion of this application can be grounds for denial of certification, or in the case Of a certificateholder, reprimand, suspension, or revocation of the educational certi ficate, credential, or l icense.

14/1) 5eodtl.e !WASIGNATURe DATE CITY!STATE

THE FOLLOWING AFFIDAVlT MUsr BE COMPLETED BY WASHtNGTON COLLEGE/UNIVERSITYSTUDENTS AND THOSE COMPLETING A PESS APPROVED TRAINING PROGRAM.

I hereby authorize __ ~~_~cc;---:::--;:--~ __ -;---;-c--;" to release, orally or in writing as may be requested, a\l student(name of Insti tution Dr org aruzatlon)

records and other personally identif iable information 10 the Office of the Super intendent of Public instruction (OSPI) for thepurpose ofinvestig

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O FF IC E O F S UP ER IN TE ND EN T O F P UE lU C IN ST RU CT IO NPro fe ss lo oa l ce r1 if ica t io nOkl Capito l B(j!djng, PO BOX 4nllOOLYMP IA WAI I85 I J 4 .- 7200

( 360) 72~OO TIY (36 0) 664-3fJ31Weh Site: !rtIp:llWfWJ