Get Psc Verification Form

Georgia PSC Experience Verification Form Revised March 2012 200 Piedmont Avenue Suite 1702 Atlanta GA 30334-9032 Please Use Black Ink or Type Please use ALL CAPS and print your name as you wish it to appear on your certificate Title Last name Mr Ms Dr First name Middle or Maiden Name Social Security Number Date of Birth MM/DD/YY - / The Experience Verification Form is used to verify educational work experience. You must submit this form if a you are requesting certification for Teacher Support Specialist b you have taught full time in a PSC-accepted accredited college during the last five years c you are using out of state school experience 3 satisfactory years within the last 5 years in lieu of a GACE Content Assessment and/or other special Georgia requirements d you have a minimum of one year in the past five of full-time certified school experience out-of state to meet recency. Employer Section The information listed below is to be completed by the current or previous employer Superintendent Headmaster Agency Director or Designated Personnel Officer. Principals are not authorized to sign this form unless they are the designated personnel officer. Please note that if verifying college experience only full-time college experience can be accepted* One year of full-time teaching experience at a college or university is defined as teaching 9 semester hours each semester for two consecutive semesters. Use one line for each change in status. Do not include leave of absence periods. Please verify only full-time or consecutive years of half-time educational employment experience. Regional Certificate Or State Dates of Service Ratings on Grades Subjects Held School District Accreditation Performance Taught Major Portion From To Or Institution Specify Reviews of School Day mm/dd/yy Yes/No Agency Satisfactory If Special Education was taught please identify the disability served e*g* BD LD MR cross-categorical etc* If Middle Grades or Special Education was taught please identify the specific academic subject area s Name of Authorized Official Please print or type Signature of Authorized Official School System Agency Private Institution Phone number Email address City State Zip Date. You must submit this form if a you are requesting certification for Teacher Support Specialist b you have taught full time in a PSC-accepted accredited college during the last five years c you are using out of state school experience 3 satisfactory years within the last 5 years in lieu of a GACE Content Assessment and/or other special Georgia requirements d you have a minimum of one year in the past five of full-time certified school experience out-of state to meet recency. Employer Section The information listed below is to be completed by the current or previous employer Superintendent Headmaster Agency Director or Designated Personnel Officer. Employer Section The information listed below is to be completed by the current or previous employer Superintendent Headmaster Agency Director or Designated Personnel Officer. Principals are not authorized to sign this form unless they are the designated personnel officer. Please note that if verifying college experience only full-time college experience can be accepted* One year of full-time teaching experience at a college or university is defined as teaching 9 semester hours each semester for two consecutive semesters.