Licensed Verification HR – 8/2017
xxx-xx-_______
Instructions:
This form is used to determine placement on the salary schedule
for New
Hires with the Jordan School District.
Please provide Official Verification of Experience (under contract)
with a valid license, in your district.
Substitute experience is not counted as contract.
Service credit cannot be given without verification of experience.
Address: Street, City, State, Zip Code
Employee Signature: I hereby give permission to release the information requested below to the
Human Resource Department of Jordan School District.
Which Service Was
Contract
Days
Served
Day
Employed
Time
Time
%
Is a license required for position(s) listed above? ..................................................................
Is school accredited and recognized by the U.S. Department of Education?.............................
Years_______
______ Months ____________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT ACCORDING TO OUR OFFICIAL RECORDS:
Signature of Certifying Officer
OFFICIAL VERIFICATION OF EMPLOYMENT
7387 S. Campus View Drive • West Jordan, UT 84084
PHONE: 801-567-8150 • FAX: 801-567-8056
Name under which service was rendered if different
Please mail or fax to the Jordan School District Human Resources Department, at the address or fax number above.
To be completed by employee
To be completed by employer
Yes
Yes
No
No
