CJ
CJ
CJ
OFFICE OF SUPERINTENDENT OF PUBLIC INSTRUCTION
Professional Certification
Old Capitol Building, PO BOX 47200
OLYMPIA WA 98504-7200
(360) 725-6400 TTY (360) 664-3631
Web Site: http:/ /www.k12.wa.us/certification/
E-Mail: cert@k12.wa.us
VERIFICATION OF EXPERIENCE
USE THIS FORM IF YOU HAVE AT LEAST THREE YEARS OF OUT-OF-STATE EXPERIENCE IN SCHOOLS.
SECTION I
TO BE COMPLETED BY APPLICANT
Fill out Section I and send it to your employer(s). When this form has been returned to you, include it in your application packet
with a copy of your out-of-state certificate.
1. NAME LAST FIRST MIDDLE MAIDEN/FORMER NAME
2. ADDRESS 3. DATE OF BIRTH
CITY/STATE/ZIP 4. SOCIAL SECURITY NO. (OPTIONAL)
5. TELEPHONE:
BUSINESS
( )
HOME
( )
6. E-MAIL
Attach copies of these documents. If they are coded, include photocopy of official explanation of code.
Title of
Certificates/Licenses
Issuing State, Province,
or City
Effective Date Expiration Date
Valid for What Subjects,
Areas or Professions
Verification of three years of appropriate service in the respective role (teacher, educational staff associate, administrator) is required.
If verifying experience for more than one employer, photocopy this form and send to each employer.
SECTION II
TO BE COMPLETED BY EMPLOYER, OR HIS/HER DESIGNEE, WHERE APPLICANT WAS EMPLOYED
Based on personnel records, this statement MUST be prepared and signed by the superintendent or the personnel director of the
school district or private school where the applicant was employed. Stamped signatures MUST be initialed by the individual using
the stamp. Please return the completed form directly to the applicant
.
SCHOOL DISTRICT APPLICANT’S POSITION TITLE
FROM TO
IF PERSON SERVED IN DUAL ROLE, INDICATE PERCENTAGE
OF FULL-TIME EQUIVALENCY IN EACH ROLE:
NUMBER OF DAYS OF
SERVICE EACH YEAR:
SERVICE WAS: FULL-TIME FROM TO
(DATE) (DATE)
SERVICE WAS:
PART-TIME FROM TO
(DATE) (DATE)
SERVICE WAS:
SUBSTITUTE FROM TO
(DATE) (DATE)
ADDRESS PRINTED NAME
CITY/STATE/ZIP TITLE OF PERSON COMPLETING FORM
SIGNATURE DATE TELEPHONE
( )
E-MAIL
RETURN COMPLETED FORM TO APPLICANT
FORM SPI/CERT 4020F-1 (Rev. 9/15)
