Get WI DPI PI-1613 2010

INSTRUCTIONS TO EMPLOYER Mail completed form to Wisconsin Department of Public Instruction EMPLOYMENT VERIFICATION PI-1613 Rev. 01-10 WI DEPARTMENT OF PUBLIC INSTRUCTION EDUCATOR LICENSING P. Mail the completed form to DPI Educator Licensing P. O. Box 7841 Madison WI 53707-7841. 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 Type of Teacher Principal Aide Other Position Specify Grades Taught Subjects Taught Regular Substitute 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 Title Employer Telephone Area Code/No. Collection of social security number is a requirement of s. O. BOX 7841 MADISON WI 53707-7841 Phone Number 800 266-1027 or 608 266-1027 Website dpi. wi. gov/tepdl This form is available at dpi. wi. gov/tepdl/applications. html 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. 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. Mail the completed form to DPI Educator Licensing P. O. Box 7841 Madison WI 53707-7841. 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 Type of Teacher Principal Aide Other Position Specify Grades Taught Subjects Taught Regular Substitute 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 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. O. BOX 7841 MADISON WI 53707-7841 Phone Number 800 266-1027 or 608 266-1027 Website dpi. wi. gov/tepdl This form is available at dpi. wi. gov/tepdl/applications. html 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. wi. gov/tepdl/applications. html 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. 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. .