Employment Verification Form For Teachers, School Service Providers, And Administrators
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1Division of Education Excellence - Office of Educator Licensure and Quality
rd
51 N Street NE, 3
Floor / Washington, DC 20002 /
educator.licensurehelp@dc.gov
Employment Verification Form for Teachers, School Service Providers, and
Administrators
This form must be completed by an employing official in the Office of Human Resources at the appropriate public or nonpublic
school division and must contain all original signatures where required (a copy of the school district’s official employment
record may be submitted in lieu of this form). Once completed by the appropriate official, this form should be returned to the
applicant sealed in an official agency envelope. The applicant must then submit the sealed envelope along with other required
documentation to apply for a District of Columbia license.
TO BE COMPLETED BY APPLICANT
Employee Last Name
Employee First Name
M.I.
SSN
_________/ ________/ _________
Maiden name(s) or other names used
Date of Birth
Gender
________/ ________/ _________
Male
Female
Street Address
City and State
Zip code
Contact numbers
:
Daytime
:
Evening
Name of School
City/State
Position title
Subject(s) and grade level taught
Applicant consent and affirmation
By checking this box, I hereby authorize the OSSE to share or obtain any information regarding this application with a previous, current,
potential employer, or other licensing entity for use in this application process.
By my signature, I certify that the information listed on this form is accurate, complete and true. I understand that any finding of
misrepresentation may result in the denial and/or revocation of my application and/or license/certificate.
____________________________________________________________________________________
Applicant Signature
Date
EMPLOYER VERIFICATION - (To be completed by Authorized official in the employing agency’s Office of Human Resources / Personnel.)
Type of School
Name of School District / County / Parish, etc.
P
ublic
Charter
Private
Is the school
Position title (e.g. teacher,
Start month/year –
Name of School where employed
Subject and grade level taught
accredited?
counselor, principal, etc.)
Ending month/year
YES
NO
1)
YES
NO
2)
The employee named on this form has completed ____
yrs ____ months of full-time K-12 school based teaching experience (not substitute experience).
The employee named on this form has completed ____
yrs ____ months of full-time K-12 school based pupil services work experience.
The employee named on this form has completed ____
yrs ____ months of full-time K-12 school based administrator work experience.
You would rate the employment services provided by this employee as:
Superior
Satisfactory
Unsatisfactory
Not known
Signature of Verifying Official
Print Name
Position Title
Contact number
Once completed by the School District Employing Official, Human Resources rep. or other certifying official, this form MUST be mailed
back to the applicant sealed in an agency envelope. This form MUST bear all original signatures. Photocopies will not be accepted.
4/2009
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