VERIFICATION OF K-12 EDUCATOR EXPERIENCE

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er' Please return this form to the employee. Do not send it directly to the Licensure Section. Pr#fessi#nal Ed$cat#r *K-12+ E)"erience *t# %e c#m"leted % em"l# er+
(e.innin. date #f ser-ice *m#nt&/ da / ear+ Endin. date #f ser-ice *m#nt&/ da / ear+ T#tal &#$rs 0#r1ed "er 0ee1 f$ll-time "art-time P#siti#n title *e2.2/ teac&er/ c#$nsel#r/ s$"er-is#r/ "rinci"al/ s$"erintendent+

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K-12 Instructional Teacher ssistant !xperience "to #e completed #y employer$ (e.innin. date #f ser-ice *m#nt&/ da / ear+ Endin. date #f ser-ice *m#nt&/ da / ear+ T#tal &#$rs 0#r1ed "er 0ee1 I%P&'T (T) C&ec1 #ne %#) %el#0 f#r eac& assi.nment2
T&e assi.nment meets t&e criteria statement3 %el#02

Please use a separate line for each school year2

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*+'IT!'I ST T!%!(T) The instructional teaching assistant assignment listed above was service in the classroom with school-age children with actual instructional teaching responsibilities comprising a minimum of 50% of daily activities.
I certif t&at t&is -erificati#n #mits lea-e #f a%sence "eri#ds and t&at all inf#rmati#n is c#m"lete and c#rrect acc#rdin. t# t&e #fficial rec#rds #f t&is sc&##l s stem2

si.nat$re #f s$"erintendent #r desi.nee

date

address

title
P$%lic ,c&##ls #f N#rt& Car#lina De"artment #f P$%lic Instr$cti#n 5icens$re ,ecti#n 6768 9ail ,er-ice Center Ralei.&/ N#rt& Car#lina 2:6;;-6768

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F#r e)"erience as a "r#fessi#nal ed$cat#r' >a-e F#rm E *Verificati#n #f E)"erience+ c#m"leted % #$r f#rmer em"l# er*s+2 If #$ are s$%mittin. e)"erience fr#m m#re t&an #ne em"l# er/ &a-e eac& #ne c#m"lete a se"arate f#rm2 F#rm E ma %e c#"ied as needed2 Please n#te t&at #nl e)"erience #f #ne-&alf time #r m#re *fifteen &#$rs "er 0ee1+ 0ill %e c#nsidered in t&e e-al$ati#n2 !xperience as a K-12 professional educator "teacher, counselor, principal, etc.$ s&#$ld %e re"#rted in (#) A2 All re?$ested inf#rmati#n m$st %e s$""lied2 (e.innin. and endin. dates m$st incl$de m#nt&/ da / and ear2 !xperience as a K-12 instructional teacher assistant s&#$ld %e re"#rted in (#) (2 All re?$ested inf#rmati#n m$st %e s$""lied2 (e.innin. and endin. dates m$st incl$de m#nt&/ da / and ear2 Em"l# ers m$st indicate 0&et&er #r n#t eac& ear #f e)"erience meets t&e criteria f#r credit % c&ec1in. t&e a""r#"riate %#) in t&e ri.&t &and c#l$mn2 Su#mittin- .orm ! If t&is f#rm is %ein. s$%mitted se"aratel fr#m an initial #r rene0al a""licati#n/ "lease mail t&e c#m"leted f#rm al#n. 0it& a @882<< e-al$ati#n fee t#' De"artment #f P$%lic Instr$cti#n 5icens$re ,ecti#n 6768 9ail ,er-ice Center Ralei.&/ N#rt& Car#lina 2:6;;-6768

4#$ ma "a % "ers#nal c&ec1/ m#ne #rder/ certified c&ec1 made "a a%le t# t&e De"artment #f P$%lic Instr$cti#n/ Visa #r 9astercard 2 If #$ 0is& t# "a % credit card/ fill #$t t&e credit card "a ment f#rm and mail t# t&e a%#-e address #r fa) it t# *;1;+ =<:778<2 >i.&li.&ted inf#rmati#n is %lac1ed #$t and $nreada%le % #$r di.ital scannin. s stem2 Please d# n#t $se &i.&li.&ters #f an c#l#r #n #$r d#c$ments2 >i.&li.&ted d#c$ments ma %e ret$rned t# #$2
Please d# n#t f#ld/ sta"le/ #r $se "a"er cli"s t# #r.ani!e t&ese materials2 D#in. s# 0ill sl#0 d#0n t&e a$t#mated a""licati#n "r#cess and dela #$r res"#nse2 Please mail t&e d#c$ments in a ;A ) 12A en-el#"e2 T&an1 #$2

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N#n-teac&in. B#r1 E)"erience can n#t %e re?$ested $sin. t&is f#rm2 Re?$ests f#r N#n-teac&in. B#r1 E)"erience m$st %e s$%mitted t&r#$.& t&e "ers#nnel #ffice #f t&e em"l# in. NC sc&##l s stem $sin. F#rm NE2

P$%lic ,c&##ls #f N#rt& Car#lina De"artment #f P$%lic Instr$cti#n 5icens$re ,ecti#n 6768 9ail ,er-ice Center Ralei.&/ N#rt& Car#lina 2:6;;-6768

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