Employment Verification
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1
2Employment Verification
As a CTNS Recipient, you have agreed to be employed in a critical teaching needs occupation in the State of South Dakota for five years
after graduating from a participating postsecondary institution.
Recipient Section - To Be Completed by Recipient:
Last Name
First Name
MI
Social Security Number
Home Area Code/Telephone Number
Permanent Street Address (include PO box address if applicable)
City
State
Zip Code
Date of Birth (Month/Day/Year)
E-mail Address
Driver’s License State and Number
State
#
Check the critical need occupation in which you are employed:
___ Teacher - High School Science
___ Teacher - Elementary or Secondary Special Education
___ Teacher - High School Career & Technical Education
___ Teacher - High School Math
Recipient’s Signature _______________________________________________________________________
Date ____________________________
To Be Completed By the Human Resource Office:
Recipient’s Employment Title
Date Employment Began / Will Begin
Full Time Position
Yes
No
Employer Name
Address
City
State
Zip Code
Phone Number
My Signature Verifies that this individual is employed at our organization in the field and position indicated above.
Signature _______________________________________________________________________
Date ____________________________
Name (Printed) ___________________________________________________________________
Title ____________________________________________________________________________________
PLEASE RETURN THE COMPLETED FORM TO:
South Dakota Board of Regents
Critical Teaching Needs Scholarship Program
306 East Capitol Ave, Suite 200
Pierre, SD 57501
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