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 NON-INSTRUCTIONAL EXPERIENCE | | |
| | | | | |
|SECTION II – COMPLETED BY FORMER EMPLOYER | | | | |
(FORMER EMPLOYER PLEASE USE A SEPARATE LINE FOR EACH YEAR)
|SCHOOL YEAR | |DATES OF SERVICE |ACTUAL NO. OF |NO. OF HOURS WORKED PER | |FULL TIME or |
|Year to |NAME OF SCHOOL/BUSINESS |FROM: M/D/Y TO: M/D/Y |DAYS EMPLOYED |DAY |SPECIFIC ASSIGNMENT |PART TIME |
|Year | | | | | | |
| | | |
| |Name | |
|was employed at | | |Sworn to and subscribed before me this |
| |Organization | | |
| | | |Seal and Signature of Notary Public |
| | | | |
|EMPLOYER WEB ADDRESS | | | |
| | | |My Commission Expires |
|SIGN NAME | | | |
| | | |(MUST BE NOTARIZED OR AFFIX SCHOOL BOARD SEAL) |
|PRINT NAME | | | |
| | | | |
|TITLE | | | |
| | |
|PHONE |( ) - Ext. |
| | |
-----------------------
OFFICE USE ONLY
SAP # __________
_______yrs = ________steps
_______yrs/2 = ________steps
Approved by ________________ Date ______
................
................
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