Form Te 4131 - Professional Or Occupational Certificate - Michigan Work Experience Report
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1TE 4131 Rev. 02/12
WORK EXPERIENCE REPORT FORM FOR MICHIGAN
PROFESSIONAL OR OCCUPATIONAL CERTIFICATE
Instructions:
If you are applying for the Professional or Occupational certificate, this form must be completed by the
Superintendent or Chief Official of the employing school district or school and submitted with your application
documents.
CANDIDATE IDENTIFIERS
(REQUIRED IDENTIFIER)
(SELECT ONE or MORE OPTIONAL IDENTIFIERS)
Last 4-digits of
PIC: ______________________________
Social Security #: _XXX-XX-___________
(available through Michigan Online Educator Certification System
)
Date of Birth: _________________________
Michigan University Student ID #: ________________________
MOECS Application #: _________________
Name of School District
or School in Which
Candidate was Employed
School District’s/School’s Address:
CERTIFICATION OF TEACHING EXPERIENCE IN A REGULAR ASSIGNMENT
This is to certify that _________________________________________________________________________________
(
first name)
(middle/maiden name)
(last name)
taught full-time (2 ½ clock hours or more a day) from ________________________ to __________________________
(
month)
(day)
(year)
(month)
(day)
(year)
in grade(s) _______________ and subject(s) _____________________________________________________________.
CERTIFICATION OF SUBSTITUTE TEACHING EXPERIENCE (if applicable)
This is to certify that _________________________________________________________________________________
(
first name)
(middle/maiden name)
(last name)
substitute taught from ________________________ to _________________________ in grade(s) _________________
(
month)
(day)
(year)
(month)
(day)
(year)
and subject(s) _________________________________________________ for a total of _______________ days taught.
THIS CANDIDATE’S SERVICE IS RATED:
SATISFACTORY
UNSATISFACTORY*
*When an unsatisfactory rating is recorded, please provide an explanation on the reverse side of this page.
______________________________________________________________
________________________________
Superintendent or Chief Official’s Signature
Date
______________________________________________________________
_______________________________
Name and Title (please type or print)
Area Code/Telephone Number
THIS FORM MAY BE DUPLICATED AS NEEDED
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