Application to Exclude Previous Name from Teacher Registry

By law, Manitoba’s teacher registry must list full names (former and current) of teachers and the date their certificate was issued, as well as its class and current status. The teacher registry will not list birthdates, addresses or places of employment.


Individuals may request that a previous legal name be excluded from the teacher registry, for instance, if it may cause personal injury or hardship. The Director of Teacher Certification and Standards will consider each request on a case-by-case basis and will exclude the previous name unless doing so would not be in the public interest.

Application to Exclude Previous Name from Teacher Registry

Personal Data

Full Legal Name(s)

Mailing Address

Excluded Name

Please indicate which former names you would like to have excluded. Clearly state the reasons for which you are requesting to have a previous legal name excluded from the online teacher registry. These reasons may include how such a disclosure:

•    would not align with another enactment in Manitoba or Canada;

•    is prevented by an order issued by a court;

•    could cause injury or hardship to a person; or

•    the former name is inconsistent with the gender identity of the member.


Manitoba Education and Early Childhood Learning may further contact you to request additional documents to support your request.

Declaration

ALL declaration questions must be answered. Please answer Yes or No. For every time you answer Yes, please provide a complete explanation that includes the full identification of the registration/ licensing authority/organization concerned. Provide this information on a separate page(s).

1. Have you ever applied anywhere for authorization and/or certification to teach and had your application denied?
2. Has your authorization and/or certification to teach ever been suspended or cancelled in another jurisdiction?
3. Have you ever—for any reason other than to avoid paying renewal fees—voluntarily surrendered your authorization and/or certification to teach?
4. Have you ever—in advance of an investigation or disciplinary proceeding—either voluntarily or involuntarily restricted your teaching practice?
5. Have you ever been found guilty of professional misconduct or been found to be incompetent or incapacitated in relation to your teaching profession?
6. Has there ever been, or is there now, an investigation or proceeding in respect to your professional conduct, competence, or capacity in relation to your teaching profession, including in your teacher education program?
7. Have any terms, conditions, or limitations ever been placed on your authorization and/or certification to teach in any other jurisdiction?
8. Have you ever been asked by a teacher education program provider to withdraw from a teacher education program?
9. Have you ever been personally prevented from carrying on your occupation as a teacher as a result of any criminal, civil, or disciplinary proceeding in any jurisdiction?
10. Have you ever agreed to a settlement or a resignation to avoid any proceeding or disciplinary action with respect to your professional conduct, competence, or capacity, in relation to either a teaching position or your professional certification?
11. Have you ever been terminated or had restrictions imposed on your employment as a teacher by an employing school district, education authority, or other organization in respect of your conduct, competence, or capacity?
12. Have you ever been subject to an investigation or proceeding relating to working with children or students in capacities other than teaching?
13. Have you ever been found guilty of professional misconduct or been found to be incompetent or incapacitated in relation to another profession?
14. Has there ever been, or is there now, an investigation or proceeding in respect to your professional conduct, competence, or capacity in relation to another profession?

Manitoba Education and Early Childhood Learning may further contact you to request additional documents to support your declarations.

Criminal Record Declaration

Please answer “Yes” or “No”. For every time you answer “Yes”, please provide a complete explanation of the offence that includes the full identification of the police/court authority concerned.

1. Have you ever been found guilty of a criminal offence?
2. Have you ever been found guilty of any offence relevant to your suitability to practice the profession?
3. Are there any criminal charges pending against you?
Have you ever been placed on a child (or other) abuse registry in Manitoba, or any other jurisdiction?

Note

Providing false or incomplete information may be considered professional misconduct and grounds for rejection of your application.

Manitoba Education and Early Childhood Learning may further contact you to request additional documents to support your declarations.

Final Declaration

I declare that all information given on this application is true, correct and complete to the best of my knowledge.


I consent to Manitoba Education and Early Childhood Learning making inquiries and exchanging information with any jurisdiction or registration authority.


I agree that if there are any changes to the information I have provided to Manitoba Education and Early Childhood Learning in this application, I will immediately advise Manitoba Education and Early Childhood Learning and provide the new information.


I declare that all documentation submitted by me in relation to my application has not been changed or altered in any way. I agree that Manitoba Education and Early Childhood Learning reserves the right to request further documentation if required.

(Last Name, and First Name)

This personal information is being collected under the authority of The Education Administration Act, and will be used for ongoing verification of certification, notification, and data analysis. Personal information is protected under The Freedom of Information and Protection of Privacy Act.

Please return the form by clicking submit below.


Alternatively, you can submit the form and additional information by Fax at 204-945-1625, or by mail to:

Teacher Certification and Standards

Branch 309-1181 Portage Ave.

Winnipeg, MB R3G 0T3

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