VERIFICATION OF K-12 EDUCATOR EXPERIENCE
last name first name middle name maiden name
street address city state zip code
social security number email address
? To the employer: Please return this form to the employee. Do not send it directly to the Licensure Section.
Box A Professional Educator (K-12) Experience (to be completed by employer) School system Total hours Beginning date of Position title (e.g., teacher, Ending date of service worked per week service counselor, supervisor, Public Private (month, day, year) full-time (month, day, year) principal, superintendent) part-time
Box B K-12 Instructional Teacher Assistant Experience (to be completed by employer) School system IMPORTANT: Beginning date Ending date Total hours worked per of service of service Check one box below for each week assignment. (month, day, year) (month, day, year)
The assignment meets the criteria Please use a separate line for each school year. statement* below.
The instructional teaching assistant assignment listed above was service in the classroom with school-age children
with actual instructional teaching responsibilities comprising a minimum of 50% of daily activities.
I certify that this verification omits leave of absence periods and that all information is complete
and correct according to the official records of this school system.
signature of superintendent or designee date address
title telephone city, state, and zip code Public Schools of North Carolina Department of Public Instruction Licensure Section 6365 Mail Service Center Form E Raleigh, North Carolina 27699-6365 August 2008
Experience Credit: How to Apply
For experience as a professional educator:
Have Form E (Verification of Experience) completed by your former employer(s). If you are
submitting experience from more than one employer, have each one complete a separate form. Form E
may be copied as needed. Please note that only experience of one-half time or more (fifteen hours per
week) will be considered in the evaluation.
Experience as a K-12 professional educator (teacher, counselor, principal, etc.) should be
reported in Box A. All requested information must be supplied. Beginning and ending dates must
include month, day, and year.
Experience as a K-12 instructional teacher assistant should be reported in Box B. All requested
information must be supplied. Beginning and ending dates must include month, day, and year.
Employers must indicate whether or not each year of experience meets the criteria for credit by
checking the appropriate box in the right hand column.
Submitting Form E
If this form is being submitted separately from an initial or renewal application, please mail the
completed form along with a $55.00 evaluation fee to:
Department of Public Instruction
6365 Mail Service Center
Raleigh, North Carolina 27699-6365
You may pay by personal check, money order, certified check made payable to the
Department of Public Instruction, Visa or Mastercard . If you wish to pay by credit card,
fill out the credit card payment form and mail to the above address or fax it to (919)
Highlighted information is blacked out and unreadable by our digital scanning system.
Please do not use highlighters of any color on your documents. Highlighted documents
may be returned to you.
Please do not fold, staple, or use paper clips to organize these materials. Doing so will
slow down the automated application process and delay your response. Please mail the
documents in a 9" x 12" envelope. Thank you.
Note: Non-teaching Work Experience can not be requested using this form.
Requests for Non-teaching Work Experience must be submitted through the
personnel office of the employing NC school system using Form NE.
Public Schools of North Carolina Department of Public Instruction Licensure Section 6365 Mail Service Center
Raleigh, North Carolina 27699-6365 August 2008