GOLDEN APPLE SCHOLARS OF ILLINOIS
EMPLOYMENT VERIFICATION FORM
To be completed by Scholar:
Name: __________________________________________________________________________________________________________________
Address: ________________________________________________________________________________________________________________
City, State, Zip: __________________________________________________________________________________________________________
Home Phone: ____________________________________________________________________________________________________________
Cell Phone: ______________________________________________________________________________________________________________
Personal Email (Non-District): _____________________________________________________________________________________________
School of Employment: ____________________________________________________________________________________________________
School District: __________________________________________________________________________________________________________
School Address: __________________________________________________________________________________________________________
School City, State, Zip: ____________________________________________________________________________________________________
School County: ___________________________________________________________________________________________________________
School Phone: ____________________________________________________________________________________________________________
Subject(s): _______________________________________________________________________________________________________________
Grade Level: _____________________________________________________________________________________________________________
School-Related Extracurricular/Athletics: ___________________________________________________________________________________
Principal’s Name: ________________________________________________________________________________________________________
Principal’s Email Address: _________________________________________________________________________________________________
Beginning Date of Employment: ____________________________________________________________________________________________
Illinois Educator Identication Number: _____________________________________________________________________________________
To be completed by School Ofcial:
I verify that __________________________________ is employed in a full-time teaching position at the school listed above.
Name of School Principal, Assistant Principal, Director of Human Resources or Superintendent
(Please Print) _____________________________________________________ (Title) _________________________________________________
______________________________________________________________________________ ________________________________________
Signature of the aforementioned person Date
Golden Apple Foundation
8 South Michigan Avenue, Suite 700
Chicago, IL 60603
Email this form to: employmentverications@goldenapple.org
EVERY TEACHING SCHOLAR MUST COMPLETE THIS FORM EVERY SCHOOL YEAR AND
RETURN TO GOLDEN APPLE TO RECEIVE CREDIT TOWARD YOUR TEACHING COMMITMENT
School Year: ___________________
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