Verification Of Prek-12 Teaching Experience - Arizona Department Of Education

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ALERT: Do not use this form for
certificate conversions.
Converting a 3-year Provisional
teaching certificate to a 6-year
Standard requires an "Application to
Convert a Provisional..."
ARIZONA DEPARTMENT OF EDUCATION - CERTIFICATION UNIT
Mailing Address: P.O. Box 6490, Phoenix, AZ 85005-6490 • Telephone: (602) 542-4367
Verification of PreK-12 Teaching Experience
This form must be completed by a district superintendent or human resources
director, or by a charter or private school administrator. This form will NOT be
accepted if any section of the form is completed or altered by the applicant.
Part 1: Teacher Information
Last Name
First Name
Educator ID or Social Security
Number
Part 2: Verification of teaching experience. Include full-time teaching experience ONLY. Do NOT
include part-time teaching, substitute teaching, or paraprofessional experience.
Beginning Date
End Date of
Grade Level(s)
Disability Area(s)(Special
Subject or Specialized
of Service
Service
Education Teachers
Area(s) (e.g., ESL, Gifted,
(MM/DD/YY)
(MM/DD/YY)
ONLY)
Music, CTE)
S
S
/P
T
IGNATURE OF
UPERINTENDENT
ERSONNEL OFFICER
ITLE
N
D
S
P
N
D
AME OF
ISTRICT OR
CHOOL
HONE
UMBER
ATE
Revised 11-8-2016

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