District Verification for Principal Licensure Candidates
Department of Human Services, 91 Killian Building Lane, Room 208
Western Carolina University, Cullowhee, NC 28723
Please have a district personnel officer verify the following information. The candidate should then scan
the completed form and submit it as a PDF file through ApplyYourself. Alternatively, the form may be
submitted as a word document form if the personnel officer provided an electronic signature.
Applicant’s Name:
Employer:
School Name:
School Address:
School Phone #:
School Fax #:
Date: ______________________
Full years of experience (career):
_____ 0-2 _____ 3-4 _____ 5+ _____ Teaching _____ Counselor _____ Other
Applicant has a health certificate on record with the employer: Yes _____ No _____
Applicant has a background check on record with the employer: Yes _____ No _____
Name: ___________________________________________ Signature: ___________________________
Title: ______________________________________________ Phone: ____________________________
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