Get WI DPI PI-1613 2014

INSTRUCTIONS TO EMPLOYER Complete Sections II and III and return to applicant. Wisconsin Department of Public Instruction EMPLOYMENT VERIFICATION Phone Number 800 266-1027 or 608 266-1027 Website tepdl.dpi. wi. gov PI-1613 Rev. 01-14 This form is available at tepdl.dpi. wi. gov/licensing/supplementary-forms To the Applicant Complete Section I print or type and then send to your employer district administrator or personnel director for completion of Sections II and III. INSTRUCTIONS TO EMPLOYER Complete Sections II and III and return to applicant. Wisconsin Department of Public Instruction EMPLOYMENT VERIFICATION Phone Number 800 266-1027 or 608 266-1027 Website tepdl*dpi. wi. gov PI-1613 Rev* 01-14 This form is available at tepdl*dpi. wi. gov/licensing/supplementary-forms To the Applicant Complete Section I print or type and then send to your employer district administrator or personnel director for completion of Sections II and III. After it has been returned to you scan and upload when applying for a license using ELO. To the Employer Please complete both Sections II and III. In Section II list each separate position/assignment held by the applicant within your district on an individual line. Return the completed form to the applicant. I. APPLICANT INFORMATION Social Security Number Name Last First Middle Other/Previous Name of Employing School District / Agency Location of Employment School s City State II. EMPLOYMENT HISTORY Dates MM/YY Position Detail If Teacher From To Position Held Counselor Principal Type of Teacher Aide Other Position Specify Regular Substitute Subjects Taught Grades Taught III. EMPLOYER VERIFICATION TO THE BEST OF MY KNOWLEDGE all information presented on this form is accurate and the education employment listed above was successful* Exceptions Limitations or Other Comments Name of School District or Employer Street Signature of Employer City State Zip Code Date Signed Mo. /Day/Yr. Title Employer Telephone Area Code/No* Collection of social security number is a requirement of s. 118. 19 1m and 1r. The social security number may be released to the Department of Justice Department of Revenue and the Department of Workforce Development. wi. gov PI-1613 Rev* 01-14 This form is available at tepdl*dpi. wi. gov/licensing/supplementary-forms To the Applicant Complete Section I print or type and then send to your employer district administrator or personnel director for completion of Sections II and III. After it has been returned to you scan and upload when applying for a license using ELO. To the Employer Please complete both Sections II and III. After it has been returned to you scan and upload when applying for a license using ELO. To the Employer Please complete both Sections II and III. In Section II list each separate position/assignment held by the applicant within your district on an individual line. In Section II list each separate position/assignment held by the applicant within your district on an individual line. Return the completed form to the applicant. I. APPLICANT INFORMATION Social Security Number Name Last First Middle Other/Previous Name of Employing School District / Agency Location of Employment School s City State II. .