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4. Have you ever had ANY [professional] certificate, license, or permit, or an application for same, revoked, suspended, limited, or denied? Yes No 5. Have you ever surrendered ANY [professional] certificate, license, or permit? Yes No
If you meet the standard for good moral character as defined in paragraph three of this document, please sign the following assurance of good moral character:
I, ________________________________, assure Community Synergy Tutoring that I am of good moral character, as defined in the third paragraph of this document.
If you can accurately and honestly answer NO to all of the questions listed in paragraph four, please sign the following statement:
I, ________________________________, assure Community Synergy Tutoring that I can accurately and honestly answer NO to all of the questions listed in paragraph four.