Postsecondary Verification Form
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1West Virginia Adult Education
Postsecondary Verification Form
Information collected on this form will be aggregated and used for state and federal reports on
students enrolled in West Virginia Adult Education Programs. Information on individuals will be
protected as confidential.
Learner Name:
_________________________________________________________________________
last
first
middle
maiden
Date of Birth:_________/________/________ Social Security Number:________/_______/_______
Month
Day
Year
Exit / Withdrawal Date:______/_______/_______
Month
Day
Year
Enrolled in School/Training Facility:__________________________________________________
(i.e. Bethany College, Valley College, University of Phoenix, Charleston School of Beauty Culture, Military)
Program / Training:_______________________________________________________________
[i.e. CNA, Business, Engineering, Forestry, Education, Cosmetology, Military (specify branch), Real Estate]
Date of Enrollment:_______________________________________________________________
(Sometime during the year of exit / withdraw or prior to June 30 of the following program year)
Private WV College / University
Public WV College / University
Out-of-State Post-secondary / Job Training
Private / Local Training Outside of WV’s K-12 System
On-line Post-secondary / Career Technical Education (CTE)
Enrolled in Local CTE Program (West Virginia Education Information System/WVEIS)
Information was collected as follows:
Student self-reported via …
in person
phone
text
email
USPS
other, ________________________
Person listed below (not student) reported this information
_______________________________________________________________________
Name (please print)
Achieved Industry Recognized Credential
School/Training Facility:___________________________________________________________
(i.e. Bethany College, Valley College, University of Phoenix, Charleston School of Beauty Culture, Military)
Program / Training:_______________________________________________________________
(i.e. CNA, Business, Engineering, Forestry, Education, Cosmetology, Military (specify branch), Real Estate)
Private WV College / University
Public WV College / University
Out-of-State Post-secondary / Job Training
Private / Local Training Outside of WV’s K-12 System
On-line Post-secondary / Career Technical Education (CTE)
Enrolled in Local CTE Program (West Virginia Education Information System/WVEIS)
Date Credential Achieved:_________________________________________________________
(Sometime during the year of exit / withdraw or prior to June 30 of the following program year)
CTE, specify credential______________________________________________________________
Associate’s Degree, specify degree:____________________________________________________
Bachelor’s Degree, specify degree:_____________________________________________________
Master’s Degree, specify degree:_______________________________________________________
I certify that this information is correct to the best of my knowledge. By signing below, I certify that
the learner named above enrolled in and/or achieved a credential at the institution indicated above.
______________________________________________________________________________________
Printed Name of Adult Education Instructor
Date
Signature of Adult Education Instructor
Updated 7/24/2016 LM
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