PI-1613 Employment Verification
|[pic] |Wisconsin Department of Public Instruction |INSTRUCTIONS TO EMPLOYER: Complete both Sections II and III. Return |
| |VERIFICATION OF SUCCESSFUL COMPLETION OF CURRICULUM FOR |the completed form to the applicant. |
| |EXPERIENCE-BASED LICENSURE FOR TECHNICAL EDUCATION AND VOCATIONAL |Phone Number: (608) 266-1028 |
| |SUBJECTS |Website: |
| |PI-1618 (Rev. 06-18) |TO THE APPLICANT: Complete Section I (print or type) and send to your |
| | |Wisconsin School District 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 | |
| |I. APPLICANT INFORMATION | |
|Legal First Name |Middle Initial |Last Name |SSN Last 4 Digits Only |
| | | | |
|Name of Employing Wisconsin School District |Location of Wisconsin School District, City, State |
| | |
| |II. EMPLOYMENT HISTORY | |
|Dates |Completed School District Curriculum Successfully |
|MM/DD/YY |Yes |
| |No |
|From |To | |
| | | |
| |III. SCHOOL BOARD MEMBER | |
|I CONFIRM that information shown above is accurate. |
|Name of Wisconsin School District |
| |
|School District Street Address |City |State |Zip Code |
| | | | |
|Wisconsin School Board Member or Designated Administrator Name First and Last—Type or Print Legibly |
| |
|Email Address of Wisconsin School Board Member or Designated Administrator |
| |
|Signature of Wisconsin School Board Member or Designated Administrator |Date Signed Mo./Day/Yr. |
|( | |
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