VERIFICATION OF SATISFACTORY TEACHING EXPERIENCE



Polk County Public Schools, Human Resource Services

P.O. Box 391

1915 S Floral Ave

Bartow, Florida 33831

Telephone (863) 534-0781

SECTION I – COMPLETED BY APPLICANT

| | | | | | | | |

|Date | |Name | |Prior Name | |Applicant Ref. # | |

| | | |I authorize you to provide Polk County Public Schools with the following information: |

|Dates of Employment | | |Signature of Applicant _______________________________________________ |

| | | |

|VERIFICATION OF SATISFACTORY TEACHING EXPERIENCE | | |

| | | | | |

|SECTION II – COMPLETED BY FORMER EMPLOYER | | | | |

(FORMER SCHOOL SYSTEM PLEASE USE A SEPARATE LINE FOR EACH YEAR)

|SCHOOL YEAR | |DATES OF SERVICE |ACTUAL NO. OF |NO. OF DAYS IN |ACTUAL POSITION HELD |FULL TIME or |

|Year to |NAME OF SCHOOL |FROM: M/D/Y TO: M/D/Y |DAYS TAUGHT |SCHOOL YEAR |SUBJECT and/or GRADE TAUGHT |PART TIME |

|Year | | | | | | |

| | | | |

| | | |SEAL AND SIGNATURE OF NOTARY PUBLIC |

|SCHOOL ADDRESS | | | |

| | | |MY COMMISSION EXPIRES |

| | | |(MUST BE NOTARIZED OR AFFIX SCHOOL BOARD SEAL) |

|SCHOOL WEB ADDRESS | | | |

| | | | |Choose Accrediting Agency: |

|SIGN NAME | | | | |

| | | | |The Southern Association of Colleges and Schools |

| | | | |The Middle States Association of Colleges and Schools |

|PRINT NAME | | | | |

| | | | |The New England Association of Colleges and Secondary Schools |

| | | | |The North Central Association of Colleges and Secondary Schools |

|TITLE | | | | |

| | | | |The Northwest Association of Higher and Secondary Schools |

| |SUPERINTENDENT OR DESIGNEE | | |The Western Association of Colleges and Schools |

|PHONE |( ) - | | | |

| |Ext. | | | |

| | | | |Other | |

| |Please List |

-----------------------

OFFICE USE ONLY

SAP # ________________

_______yrs = ________steps

_______yrs/2 = ________steps

Approved by ______________ Date _______

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