Recipient Information:

  Name:         

  School:       

  School Address:
        

  Principal:       

  District:       

  District Address:
        

  Superintendent:       

  Endorsement Information:

  Teacher Education Program Attended (College or University):
        

  Dates Attended:     from:           to:       

  Library School Attended:
        

Dates Attended:    from:            to:   

  Type of Certificate

 MLS  LMS  Full requirement for endorsement with Lifetime Certificate

  Washington Certificate Number:

  Certificate of Recognition Information:

  What name and prefix would you like on the certificate?