PI-PDP-2 Verification form
|[pic] |Wisconsin Department of Public Instruction |INSTRUCTIONS TO EDUCATOR: Complete Part I and submit to your |
| |PDP VERIFICATION FORM |PDP Team for signature. |
| |PI-PDP-2 (Rev. 8-09) |INSTRUCTIONS TO PDP TEAM MEMBER: Complete Part II in the |
| | |appropriate team member section and return to educator. |
|Professional Development Plan (PDP) forms available at: |
| |I. EDUCATOR INFORMATION | |
|Educator Name |Educator E-Mail Address |Educator File No.* |
| | | |
|LICENSURE CATEGORY: Teacher Administrator Pupil Services |Date PDP Submitted for Verification |
| | |
|PRESENT LICENSURE STAGE: Initial Educator Professional Educator Master Educator |
|I HEREBY CERTIFY THAT, by my signature below, under penalty of perjury, that the information submitted by me in this form is true. I am aware that submitting |
|false information in connection with this process may result in non-approval and/or non-renewal of a license and may subject me to civil or criminal penalties. |
|Educator Signature |Date Signed |
|( | |
| |II. PDP TEAM MEMBER INFORMATION | |
|Team Member Name |Team Member E-Mail Address |Date Trained As a team member |Educator File No.* |
| | | | |
|Representing Check one |Check One |
|Teacher Pupil Services Administrator IHE |PDP Verified |
| |Not Verified |
|I HEREBY AFFIRM, by my signature, that the information provided is true and correct. |
|Signature |Date Signed |
|( | |
|Team Member Name |Team Member E-Mail Address |Date Trained As a team member |Educator File No.* |
| | | | |
|Representing Check one |Check One |
|Teacher Pupil Services Administrator IHE |PDP Verified |
| |Not Verified |
|I HEREBY AFFIRM, by my signature, that the information provided is true and correct. |
|Signature |Date Signed |
|( | |
|Team Member Name |Team Member E-Mail Address |Date Trained As a team member |Educator File No.* |
| | | | |
|Representing Check one |Check One |
|Teacher Pupil Services Administrator IHE |PDP Verified |
| |Not Verified |
|I HEREBY AFFIRM, by my signature, that the information provided is true and correct. |
|Signature |Date Signed |
|( | |
|Note to Applicant: Submit this completed PDP Verification Form with your license renewal application and fee to DPI. Retain one copy for your own records. |
*Educator file numbers may be found on the DPI Educator License lookup at:
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