Get Mi Te 4131 2012

TE 4131 Rev. 02/12 WORK EXPERIENCE REPORT FORM FOR MICHIGAN PROFESSIONAL OR OCCUPATIONAL CERTIFICATE Instructions If you are applying for the Professional or Occupational certificate this form must be completed by the Superintendent or Chief Official of the employing school district or school and submitted with your application documents. CANDIDATE IDENTIFIERS REQUIRED IDENTIFIER SELECT ONE or MORE OPTIONAL IDENTIFIERS Last 4-digits of Social Security XXX-XX- PIC available through Michigan Online Educator Certification System www. michigan*gov/moecs Date of Birth Michigan University Student ID MOECS Application Name of School District or School in Which Candidate was Employed School District s/School s Address CERTIFICATION OF TEACHING EXPERIENCE IN A REGULAR ASSIGNMENT This is to certify that first name middle/maiden name last name taught full-time 2 clock hours or more a day from to month day year in grade s and subject s. substitute taught from to in grade s and subject s for a total of days taught. THIS CANDIDATE S SERVICE IS RATED SUCCESSFUL When an unsuccessful rating is recorded please provide an explanation on the reverse side of this page. Name and Title please type or print THIS FORM MAY BE DUPLICATED AS NEEDED Date Area Code/Telephone Number. CANDIDATE IDENTIFIERS REQUIRED IDENTIFIER SELECT ONE or MORE OPTIONAL IDENTIFIERS Last 4-digits of Social Security XXX-XX- PIC available through Michigan Online Educator Certification System www. michigan*gov/moecs Date of Birth Michigan University Student ID MOECS Application Name of School District or School in Which Candidate was Employed School District s/School s Address CERTIFICATION OF TEACHING EXPERIENCE IN A REGULAR ASSIGNMENT This is to certify that first name middle/maiden name last name taught full-time 2 clock hours or more a day from to month day year in grade s and subject s. michigan*gov/moecs Date of Birth Michigan University Student ID MOECS Application Name of School District or School in Which Candidate was Employed School District s/School s Address CERTIFICATION OF TEACHING EXPERIENCE IN A REGULAR ASSIGNMENT This is to certify that first name middle/maiden name last name taught full-time 2 clock hours or more a day from to month day year in grade s and subject s. substitute taught from to in grade s and subject s for a total of days taught. THIS CANDIDATE S SERVICE IS RATED SUCCESSFUL When an unsuccessful rating is recorded please provide an explanation on the reverse side of this page. substitute taught from to in grade s and subject s for a total of days taught. THIS CANDIDATE S SERVICE IS RATED SUCCESSFUL When an unsuccessful rating is recorded please provide an explanation on the reverse side of this page. Name and Title please type or print THIS FORM MAY BE DUPLICATED AS NEEDED Date Area Code/Telephone Number. CANDIDATE IDENTIFIERS REQUIRED IDENTIFIER SELECT ONE or MORE OPTIONAL IDENTIFIERS Last 4-digits of Social Security XXX-XX- PIC available through Michigan Online Educator Certification System www. michigan*gov/moecs Date of Birth Michigan University Student ID MOECS Application Name of School District or School in Which Candidate was Employed School District s/School s Address CERTIFICATION OF TEACHING EXPERIENCE IN A REGULAR ASSIGNMENT This is to certify that first name middle/maiden name last name taught full-time 2 clock hours or more a day from to month day year in grade s and subject s. substitute taught from to in grade s and subject s for a total of days taught. THIS CANDIDATE S SERVICE IS RATED SUCCESSFUL When an unsuccessful rating is recorded please provide an explanation on the reverse side of this page. .