The University of the State of New York

THE STATE EDUCATION DEPARTMENT

CERTIFICATION OF COMPLETION
TRAINING IN SCHOOL VIOLENCE PREVENTION AND INTERVENTION

PART A

1.

2.

3.
4.

This form is all that you need as proof that you have completed your mandated training. On the form that
says "Send this copy to the State," complete sections 3 and 4 below, then sign and date the form. All school
employees must obtain state certification in their field. This form is just one requirement for certification.
Other requirements include the application, transcripts, fingerprinting, and, in some cases, passing exams.
For an application and further details on certification, call 1 (518) 474-3901 or visit the New York State
Education Department at www.nysed.gov
Print name exactly as it currently appears on New York State Education Department Records.
Kolpakas
Last Name:
Mary
First Name:
T
Middle Name/Initial:
Organization:
Print your address:
145 Leroy Street
Street:
Binghamton
City:
NY
13905
State:
Zip Code:
Date of Birth:
Month:
Day:
Year:
Social Security Number:
Trainee's Signature:

PART B
1.
2.
3.

TRAINEE INFORMATION

Date:

CERTIFICATION BY APPROVED TRAINING PROVIDER

Provider must complete Part B.

The EDUCATION DEPARTMENT - ORIGINAL COPY and TRAINEE COPY should be returned to the
trainee within 21 calendar days of the completion of coursework and training.
The provider of the coursework or training must retain the PROVIDER COPY. This copy must be retained
in the provider's files for not less than six years from the date the course was completed.

Pursuant to Chapter 181 of the Laws of 2000, I certify that the person indicated in Part A has completed the
required coursework or training in School Violence Prevention and Intervention.
Name of Authorized Certifying Officer
(Print or Type)

Approved Provider Name:

EMILY MCNULTY

GENIUS GENIUS OF NY, INC.

Signature of Authorized Certifying Officer:

Identification Number:

0090

Date(s) of Coursework or Training

12/05/2014

Certificate #: 180706

Send this copy to the State

The University of the State of New York

THE STATE EDUCATION DEPARTMENT
CERTIFICATION OF COMPLETION
TRAINING IN SCHOOL VIOLENCE PREVENTION AND INTERVENTION

PART A

1.

2.

3.
4.

This form is all that you need as proof that you have completed your mandated training. On the form that
says "Send this copy to the State," complete sections 3 and 4 below, then sign and date the form. All school
employees must obtain state certification in their field. This form is just one requirement for certification.
Other requirements include the application, transcripts, fingerprinting, and, in some cases, passing exams.
For an application and further details on certification, call 1 (518) 474-3901 or visit the New York State
Education Department at www.nysed.gov
Print name exactly as it currently appears on New York State Education Department Records.
Kolpakas
Last Name:
Mary
First Name:
T
Middle Name/Initial:
Organization:
Print your address:
145 Leroy Street
Street:
Binghamton
City:
NY
13905
State:
Zip Code:
Date of Birth:
Month:
Day:
Year:
Social Security Number:
Trainee's Signature:

PART B
1.
2.
3.

TRAINEE INFORMATION

Date:

CERTIFICATION BY APPROVED TRAINING PROVIDER

Provider must complete Part B.

The EDUCATION DEPARTMENT - ORIGINAL COPY and TRAINEE COPY should be returned to the
trainee within 21 calendar days of the completion of coursework and training.
The provider of the coursework or training must retain the PROVIDER COPY. This copy must be retained
in the provider's files for not less than six years from the date the course was completed.

Pursuant to Chapter 181 of the Laws of 2000, I certify that the person indicated in Part A has completed the
required coursework or training in School Violence Prevention and Intervention.
Name of Authorized Certifying Officer
(Print or Type)

Approved Provider Name:

EMILY MCNULTY

GENIUS GENIUS OF NY, INC.

Signature of Authorized Certifying Officer:

Identification Number:

0090

Date(s) of Coursework or Training

12/05/2014

Certificate #: 180706

Keep this copy for your records

IMPORTANT
READ THIS BEFORE SIGNING YOUR CERTIFICATES!
Mandated workshops are not the only item required in order to secure employment and get certified or
licensed in your profession. The document that we provide must be submitted to New York State along
with, or following, an official State application in addition to other supporting documents. If you need an
application, wish to apply online, or are unsure what other requirements you must fulfill, visit the State's
website at www.nysed.gov or call them directly at 1-518-474-3901.
If, and only if, you are certain that you have already submitted your professional application to the State, use
the information below to determine the proper office for submitting documents. Since you completed your
workshop online, there is no need to return any documents to us. Sign and date your certificate, fill in your
date of birth and social security number and send them to the State. If you have completed the workshop in
Identification and Reporting of Child Abuse and Neglect, and are not sure how to fill in sections 5 and 6,
you may leave them blank.

For Teacher Certification

(professions which involve working in a school):
New York State Education Dept, Office of Teaching, 89 Washington Ave, Albany, NY 12234

Professional License or Permit

(for all licensing that is NOT related to the Education professions):
New York State Education Department, Division of Professional Licensing Services,
[Type or Print the name of your profession]
89 Washington Avenue, Albany, NY 12234
If you are required to take a state-mandated workshop, it is likely that you will be working with children in
some context. When faced with a situation or you suspect a wrongdoing, don't hesitate. Please remember
that the safety of children may be at stake and that you can make a difference and save lives!

WWW.VIOLENCEWORKSHOP.COM
WWW.CHILDABUSEWORKSHOP.COM
WWW.AUTISMAUTISM.COM
If you found our course instructive, we would appreciate if you referred other people to our website. You
will get $5 for each person you refer to our websites. Just make sure that they enter your email address as the
referral source when they register. Referrals are processed and sent within 8-12 weeks.