OFFICE OF SUPERINTENDENT OF PUBLIC INSTRUCTION
Professional Certification
Old Capitol Building, PO BOX 47200
OLYMPIA WA 98504-7200
(360) 725-6400 TTY (360) 664-3631
Web Site: http:/ /www.k12.wa.us/certification/
E-Mail: cert@k12.wa.us
CONTINUING CERTIFICATE: VERIFICATION OF EXPERIENCE
SECTION I
TO BE COMPLETED BY APPLICANT
NAME LAST FIRST MIDDLE 1.
ADDRESS 2.
CITY/STATE/ZIP
TELEPHONE 5.
HOME
MAIDEN/FORMER NAME
DATE OF BIRTH
SOCIAL SECURITY NO. (OPTIONAL)
3.
4.
If you are applying for the continuing certificate, you will need to verify appropriate experience on this form. Applicants will need
to meet the experience requirement listed below for the continuing certificate:
Verification of 180 days of appropriate service in the respective role (teacher and administrator other than principal) of which 30
days must have been with the same employer. Substitute service in the role can be used. If verifying experience for more than
one employer, photocopy this form and send to each employer.
The continuing principal’s certificate requires three years (540 days) of service as a principal, vice principal, or assistant principal.
The Continuing ESA Certificate for the school behavior analyst, nurse, occupational therapist, physical therapist, social worker,
and speech language pathologist or audiologist role requires verification of two years full-time equivalent (FTE) experience in the
role in Washington with a school district, state-approved private school, or state agency that provides educational services for
students.
WA CERT. NO.
E-MAIL
SECTION II
TO BE COMPLETED BY EMPLOYER, OR HIS/HER DESIGNEE, WHERE APPLICANT WAS EMPLOYED
Based on personnel records, this statement MUST be prepared and signed by the superintendent or the personnel director of the
school district, private school, or administrator at the college/university where the applicant was employed. Stamped signatures
MUST be initialed by the individual using the stamp. Please return this completed form directly to the applicant.
SCHOOL DISTRICT APPLICANT’S POSITION TITLE
FROM TO
IF PERSON SERVED IN DUAL ROLE, INDICATE PERCENTAGE
OF FULL-TIME EQUIVALENCY IN EACH ROLE:
NUMBER OF DAYS OF
SERVICE EACH YEAR:
FROM TO
SERVICE WAS FULL-TIME
(DATE) (DATE)
FROM TO
SERVICE WAS
PART-TIME
(DATE) (DATE)
FROM TO
SERVICE WAS
SUBSTITUTE
(DATE) (DATE)
ADDRESS PRINTED NAME
CITY/STATE/ZIP TITLE OF PERSON COMPLETING FORM
SIGNATURE DATE TELEPHONE
RETURN COMPLETED FORM TO APPLICANT
FORM SPI/CERT 4020F (Rev. 8/19)
