Superintendent Verification of Mentored Experience
Instructions
This form is only to be used for candidates who are submitting an application for a PROFESSIONAL teaching certificate. It is to be
completed by the superintendent of schools or, if the mentored experience was completed while the candidate was employed by a non-
public school, the principal or person in equivalent position with the school.
The candidate named below is seeking Professional certification. Candidates for Professional certification are required, in accordance
with Part 80-3.4 of Commissioner's Regulations, to complete a mentored teaching experience in their first year of teaching with a
New York State Initial classroom teaching certificate. Please complete the shaded areas verifying that the candidate received a men-
tored experience in his/her first year teaching while employed by the district/BOCES/nonpublic school or was exempted from this
requirement.
_____________________________________________ __________________________________________ ________________
First Name Last Name Middle Initial
___________________________________________________ __________________________ _______________ ______________________
Street Address City State Zip Code
__________________________________________________ ________________________ _________________
Maiden Name (if applicable) Date of Birth Social Security Number
_________________________________________________________________________________________________________
Certificate Title Employed Under
Mentored Teaching Experience
(Check and Complete one of the shaded boxes only and the Attestation)
The candidate named above served as a classroom teacher and received mentoring in fulfillment of teacher certification
requirements (CR Part 80-3.4) for the Professional teaching certificate during the _________ school year. Such mentoring was
in accordance with CR Part 100.2 (dd) (iv).
The candidate named above was determined to have met conditions for a waiver to the requirement for completion of the men-
tored experience in accordance with CR Part 80-3.4. The candidate had at least 2 years of teaching experience at __________
____________________________school/school district prior to being employed in this school district under an Initial certificate.
Attestation of Chief School Officer
I confirm that the above information is correct and documentation to support this information is retained at the district for
examination by the Commissioner of Education or his/her representative.
_______________________________________________________________________________ _______________________
Signature of Superintendent/Nonpublic Chief School Officer Date
Print Name _______________________________________________________________________________________________
Superintendent's/Nonpublic Chief School Officer's Phone # _________________________________________________________
Superintendent's/Nonpublic Chief School Officer's E-mail __________________________________________________________
District/Nonpublic School Name ______________________________________________________________________________
District/Nonpublic School Address ____________________________________________________________________________
____________________________________________________________________________
Agency/Nonpublic School Code (if applicable) ___________________________________________________________________
Superintendent Verification of Mentored Experience, January 2007
