Form H - Verification Of Employment Page 2
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2Form H
Verification of Employment
Governor’s Teaching Fellowship Program
In order to comply with the terms set forth by the Governor’s Teaching Fellowship Program, verification of employment in a “low-
performing” school in California is required. A “low-performing” school is defined as a school with an Academic Performance Index
(API) ranking of 5 or less, such ranking having been established pursuant to California Education Code Section 52056(a). Upon
acceptance of employment, the fellowship awardees and the employing agency must complete their respective section of this form. The
deadline is November 8, 2013 by 5:00 P.M.
This Section to Be Completed by Fellow:
Award Year
2000-2001
(check one)
X 2001-2002
This is to certify that ________________________________________________________________________
Last Name
First
Middle
Social Security No. ___________________ Phone: (____) ____________ Email: _______________________
Who resides at: _____________________________________________________________________________
Address
City
State
Zip
Check here if contact information has changed
This Section to Be Completed by the District Director of Human Resources:
Has been officially employed in the position of _________________________Grade Level(s)______________
Full-time position
Part-time position
Date of Initial Hire at Employee’s Current School: _____________________________________ (mm/dd/yyyy)
Ending Contract Date for Employee (current school year): __________________________________________
In the County of ____________________________________________________________________________
With the _____________________________________________
(
) _________________
Name of School District
District Phone Number
at _______________________________________________
(
) _________________
Name of School
School Phone Number
____________________________________________________________________________________
School Address
City
State
Zip
School CDS Code #: ________________________________________________________________________
Principal’s Name: __________________________________________________________________________
Most current API ranking (1-10) as determined by the California Department of Education: ________________
Typed Name: ______________________________________________________
Date:_____________
(District Director of Human Resources)
Signature: ________________________________________________________________________________
(District Director of Human Resources)
This form must be submitted by District Director of Human Resources in a sealed district envelope. Please
sign across back of sealed envelope. Deadline is November 8, 2013 by 5:00 P.M.
Return to:
Governor’s Teaching Fellowship Program
For Office Use Only
P.O. Box 1590
Date of Verification:________
Long Beach, CA 90802-1590
Adm
inistrator:_____________
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