OFFICE OF SUPERINTENDENT OF PUBLIC INSTRUCTION
Old Capitol Building, PO BOX 47200
OLYMPIA WA 98504-7200
(360) 725-6400 TTY (360) 664-3631
Web Site: http:/ /www.k12.wa.us/certification/
VERIFICATION OF EXPERIENCE
USE THIS FORM IF YOU HAVE AT LEAST THREE YEARS OF OUT-OF-STATE EXPERIENCE IN SCHOOLS.
TO BE COMPLETED BY APPLICANT
Fill out Section I and send it to your employer(s). When this form has been returned to you, include it in your application packet
with a copy of your out-of-state certificate.
1. NAME LAST FIRST MIDDLE MAIDEN/FORMER NAME
2. ADDRESS 3. DATE OF BIRTH
CITY/STATE/ZIP 4. SOCIAL SECURITY NO. (OPTIONAL)
Attach copies of these documents. If they are coded, include photocopy of official explanation of code.
Issuing State, Province,
Effective Date Expiration Date
Valid for What Subjects,
Areas or Professions
Verification of three years of appropriate service in the respective role (teacher, educational staff associate, administrator) is required.
If verifying experience for more than one employer, photocopy this form and send to each employer.
TO BE COMPLETED BY EMPLOYER, OR HIS/HER DESIGNEE, WHERE APPLICANT WAS EMPLOYED
Based on personnel records, this statement MUST be prepared and signed by the superintendent or the personnel director of the
school district or private school where the applicant was employed. Stamped signatures MUST be initialed by the individual using
the stamp. Please return the completed form directly to the applicant
SCHOOL DISTRICT APPLICANT’S POSITION TITLE
IF PERSON SERVED IN DUAL ROLE, INDICATE PERCENTAGE
OF FULL-TIME EQUIVALENCY IN EACH ROLE:
NUMBER OF DAYS OF
SERVICE EACH YEAR:
SERVICE WAS: FULL-TIME FROM TO
PART-TIME FROM TO
SUBSTITUTE FROM TO
ADDRESS PRINTED NAME
CITY/STATE/ZIP TITLE OF PERSON COMPLETING FORM
SIGNATURE DATE TELEPHONE
RETURN COMPLETED FORM TO APPLICANT
FORM SPI/CERT 4020F-1 (Rev. 9/15)