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PRINT/ TYPE NAME OF OFFICIAL SCHOOL NAME SIGNATURE Return To California Student Aid Commission Specialized Programs Operations Branch APLE P. ASSUMPTION PROGRAM OF LOANS FOR EDUCATION APLE 2011-12 TEACHER EMPLOYMENT VERIFICATION FORM Phone 1-888-224-7268 3 Email aple csac.ca.gov SECTION I TO BE COMPLETED BY PARTICIPANT NAME Print or Type SSN MAILING ADDRESS EMAIL PHONE NO I did not provide eligible teaching service for the 2011-12 school year. Please explain below YES I provided eligible full-time teaching service in my designated area for the 2011-12 school year at the following school Full School Name ASAM School Circle Yes or No County School District I hereby authorize a school official to complete and release the information below to qualify me for APLE benefits. Submit to your school employment office or principal to complete Section II. PARTICIPANT SIGNATURE DATE Did the participant above provide full-time teaching service for the 2011-12 school year YES the participant was teaching at 100 of full-time for the 2011-12 school year. NO the participant was not teaching at 100 of full-time for the 2011-12 school year but did teach part-time at the following percentages as it relates to full-time teaching based on 175 teaching days per school year Total Part-Time Teaching In which grade levels did the participant teach General Elementary grade Middle School grade High School grade In which of the following areas did the participant provide full-time instruction Select all subject areas taught for the year Self-Contained All Subjects Industrial Arts Foreign Language Mathematics/Computer Education English Drama and Humanities Special Education Science Life/Physical Social Science Other Will the participant be teaching the next academic year at the current school YES Reading Specialist NO By my signature I hereby declare that the above information is true as is reflected on current official school records. O. Box 419029 Rancho Cordova CA 95741-9029 T-122 01/12 PHONE NUMBER EXT COUNTY SCHOOL DISTRICT CDE CODE Last 7-Digits For Commission Use Only Reviewer Initials Date Keyed. Submit to your school employment office or principal to complete Section II. PARTICIPANT SIGNATURE DATE Did the participant above provide full-time teaching service for the 2011-12 school year YES the participant was teaching at 100 of full-time for the 2011-12 school year. NO the participant was not teaching at 100 of full-time for the 2011-12 school year but did teach part-time at the following percentages as it relates to full-time teaching based on 175 teaching days per school year Total Part-Time Teaching In which grade levels did the participant teach General Elementary grade Middle School grade High School grade In which of the following areas did the participant provide full-time instruction Select all subject areas taught for the year Self-Contained All Subjects Industrial Arts Foreign Language Mathematics/Computer Education English Drama and Humanities Special Education Science Life/Physical Social Science Other Will the participant be teaching the next academic year at the current school YES Reading Specialist NO By my signature I hereby declare that the above information is true as is reflected on current official school records.

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