Experience Verification Form - South Carolina Department Of Education
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2Experience Verification Form
Division of Federal, State, & Community Resources
Office of Educator Services
8301 Parklane Road
Columbia, SC 29223
| web
(803)896-0368 | fax
certification@ed.sc.gov | email
Educators: Please use one form per employer.
Human Resources/Payroll Personnel: Separate entries by year. If the educator was a full-time employee, please enter the number of
days worked per year as indicated below.
Incorrect or incomplete forms will not be processed by the Office of Educator Services and will be returned to the educator.
Last Name: ______________________ First Name: _____________________ MI: ___ Former Name: ___________________
Address: ________________________________________ City: _______________________ State: ____ Zip: _____________
Social Security Number: __________________________________________________ Date: ___________________________
The following information must be completed by Human Resources/Payroll Personnel.
PreK-12 Experience
Name of School/Institution: __________________________________________________________________________
Required (check one)
Public
Private
Full Time
Part Time
Beginning Date of
Ending Date of
Days
Hours
Days
Service
Service
Position/Title | Grade | Subject
worked per
worked per
worked per
(mm/dd/yyyy)
(mm/dd/yyyy)
Year
Day
Year
1
2
3
4
Professional Education Experience
Beginning Date of
Ending Date of
Hours worked per
Organization/Company
Service
Service
Position/Title (Please attach Job Description)
Week
(mm/dd/yyyy)
(mm/dd/yyyy)
Higher Education (College & Administrative) Experience
Beginning Date of
Ending Date of
Total Semester Hours
College, University, or
Service
Service
taught between July 1 and
Position/Title | Subject
Technical Institution
(mm/dd/yyyy)
(mm/dd/yyyy)
June 30
I certify that this verification omits leave of absence periods and that all information is complete and correct according to the official
records of this school system.
HR/Payroll Personnel Signature: ___________________________________________
Date: ____________ ___________
Printed Name: _________________________________________________ Title: ______________________________________________
Address: ______________________________________________________________________ Phone: ____________________________
This form may be submitted by mail, fax, email, or hand-delivery to the contacts listed above.
Status of requests can be confirmed from the Educator Certification website. Any changes, additions or modifications to a certificate
may be confirmed and printed by the educator from the View Certification Status page on our secure website at .
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