Teacher Licensure and Accreditation - Kansas State Department of Education
VERIFICATION OF ACCREDITED EXPERIENCE
1 www.ksde.org Revised 09-22-2016
ACCREDITED EXPERIENCE means experience gained, under contract, in a school accredited by the state board or a comparable agency in another state, while the educator holds a license
with an endorsement valid for the specic assignment. A year of experience means accredited experience that constitutes one-half time or more in one school year.
A: TO BE COMPLETED BY THE APPLICANT
Last 4 digits of Social Security Number
________________________________________
Birthdate (MM/DD/YYYY)
________________________________________
Gender:
Male Female
LEGAL NAME: First Name
________________________________________
Middle Name
________________________________________
Last Name
________________________________________
All prior names (Maiden, alias, previous married, etc.)
______________________________________________________________________________________________________________________________
Mailing Address
______________________________________________________________________________________________________________________________
City
________________________________________
State
________________________________________
Zip
________________________________________
Phone
________________________________________
Alt Phone
________________________________________
Email Address
________________________________________
B: TO BE COMPLETED BY EMPLOYING SYSTEM
SCHOOL DISTRICT OR PRIVATE SCHOOL ADMINISTRATOR:
y Please complete and sign.
y Return the completed, signed hard copy in a sealed ocial school envelope to the Applicant OR email as attachment to experienceform@ksde.org. Coordinate submission with the applicant.
Name of School System
______________________________________________________________________________________________________________________________
State Accredited School and/or District?
YES NO (if not state accredited, please attach verication of accreditation status)
Name of School/District Administrator
________________________________________
Title/Position
________________________________________
Phone
________________________________________
Mailing Address
______________________________________________________________________________________________________________________________
City
________________________________________
State
________________________________________
Zip
________________________________________
I verify the above applicant was employed in our school system as listed below and the applicant’s employment qualied as accredited experience:
BEGINNING DATE
OF QUALIFYING
EMPLOYMENT
(MM/DD/YYYY)
ENDING DATE OF
QUALIFYING
EMPLOYMENT
(MM/DD/YYYY)
QUALIFYING ASSIGNMENT: List specic assignments
below ( Examples: Elementary Education K-6, Science 5-8,
Principal Prek-12, School Counselor PreK-12, Reading Specialist
PreK-12 etc.) GRADE LEVEL EMPLOYMENT IS:
full time under contract
at least 0.5 FTE but less than full-time
less than half-time
full time under contract
at least 0.5 FTE but less than full-time
less than half-time
full time under contract
at least 0.5 FTE but less than full-time
less than half-time
Signature of District Representative Date
The Kansas State Department of Education does not discriminate on the basis of race, color, national origin, sex, disability
or age in its programs and activities and provides equal access to the Boy Scouts and other designated youth groups. The
following person has been designated to handle inquiries regarding the non-discrimination policies: KSDE General Counsel,
Oce of General Counsel, KSDE, Landon State Oce Building, 900 SW Jackson, Suite 102, Topeka, KS 66612, (785) 296-3204
Teacher Licensure and Accreditation - Kansas State Department of Education
Landon State Oce Building, 900 SW Jackson Street, Suite 106
Topeka, KS 66612-1212
(785) 296-2288
(785) 296-7933 - fax
