Fillable Wisconsin DPI - Form PI-1613 Employment Verification

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Wisconsin DPI - Form PI-1613 Employment Verification

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Wisconsin Department of Public Instruction
EMPLOYMENT VERIFICATION
PI-1613 (Rev. 08-18)
INSTRUCTIONS TO EMPLOYER: Complete both Sections II and III. In Section II list each
separate position/assignment held by the applicant within your district on an individual line.
Return the completed form to the applicant.
Phone Number: (800) 266-1027 or (608) 266-1027
Website: http://dpi.wi.gov/tepdl
TO THE APPLICANT: Comp
lete Section I (print or type) and then send to your employer
(district administrator or personnel director) for completion of Sections II and III. After it has
been returned to you, scan and upload when applying for a license using ELO.
This form is available at tepdl.dpi.wi.gov/licensing/supplementary-forms
I. APPLICANT INFORMATION
Legal First Name
Middle Initial
Last Name
SSN
Last 4 Digits Only
Name of Employing School District/Agency
Location of School District or Agency,
City, State
II. EMPLOYMENT HISTORY
Dates
MM/DD/YY
II A. Employment Details
Complete separate line for each assignment
FTE
Example
1.0 or .25
II B. For Teaching Assignments Only
Complete separate line for each assignment
From
To
Type of Teacher
Grades Taught
Subjects Taught
Teacher Pupil Services Administrator
Aide Other Position Specify:
Regular Substitute Check One below:
Short Term or Long Term
Teacher Pupil Services Administrator
Aide Other Position Specify:
Regular Substitute Check One below:
Short Term or Long Term
Teacher Pupil Services Administrator
Aide Other Position Specify:
Regular Substitute Check One below:
Short Term or Long Term
III. EMPLOYER VERIFICATION
TO THE BEST OF MY KNOWLEDGE, all information presented on this form is accurate and the education employment listed above was successfully completed.
Exceptions, Limitations or Other Comments
Name of School or School District
Street Address
City
State
Zip Code
Employer’s Name First and Last—Type or Print Legibly
Employer Telephone Area Code/No.
Employer’s Email Address
Signature of Employer
Title of Employer
Date Signed Mo./Day/Yr.
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Wisconsin DPI - Form PI-1613 Employment Verification

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Completed 26 May 2020

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