....
MICHIG
AN
Departme~i Education
__________________________________________________________________ ____________________
______________________________________
________________________________________________
ADMINISTRATOR EXPERIENCE-BASED VERIFICATION
Instructions:
For those applying for the Experience-Based Administrator Certificate in accordance with School
Administrator Certification Code R380.102(2), Part II of this form may be completed by one of the
following entities:
A. The school board member, supervising administrator or Human Resources representative who
hired the educator as a superintendent, principal, assistant principal, other person whose
primary responsibility was administering instructional programs or as chief business official**
prior to January 4, 2010; OR
B. The school board member, supervising administrator or Human Resources representative who
obtained documentation from a previous employer verifying that the educator was employed as
a superintendent, principal, assistant principal, other person whose primary responsibility was
administering instructional programs or as chief business official** prior to January 4, 2010,
and, therefore, is in compliance with law.
C. If neither of the above entities can verify the educator’s employment, Michigan Association of
School Administrators (MASA) can review documentation of employment on the educator’s
behalf.
Application for certification is submitted using Michigan Online Educator Certification System (MOECS).
Once completed, this form must be emailed (MDE-EducatorHelp@Michigan.gov) or faxed to
(517-241-1670).
Part I: EDUCATOR IDENTIFIERS
Educator: ________________
_________________
__________________________
____________________
(first name) (middle/maiden name) (last name)
Identify one or more of the following:
Last 4-Digits of Social Security Number: XXX-XX-
__________________
_________________
MOECS Application Number:
________________________________
______________________________
Part II: VERIFICATION OF EXPERIENCE
This is to certify that the educator identified above was initially employed as a superintendent, principal,
assistant principal, other person whose primary responsibility was administering instructional
programs or chief business official** whose primary responsibilities included administering
instructional programs, on
__________________
at the following school or district:
______________________________________
.
(month) (day) (year) (Name of School/School District)
Verified using the following documentation*:
□
Signed/Dated Contract □ Official Letter from School with Employment Date
□ O
__________________
(*Documentation should be maintained by both employer and educator for audit purposes.)
Signature of Person Verifying Experience Date
_________________________________________________________ _____________________________
Name and Title (please print) Telephone Number
Organization/Entity Signer’s Email Address
**Certificate is available only to business/finance individuals whose exact title is “chief business official”.
Page 1 of 1 2020-9-1 v11
608 W. Allegan Street, Lansing, MI 48933 ~ Phone: 517-241-5000 ~ E-Mail: MDE-EducatorHelp@michigan.gov
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