Employee Name ________________________________________________________ SS# _________________________________________
THE FOLLOWING INFORMATION MUST BE COMPLETED BY THE PERSONNEL OFFICE OF PREVIOUS EMPLOYER
Name of School District or Educational Institution _______________________________________________________________________________
SCHOOL YEAR
DATES OF SERVICE
FROM TO
MM/DD/YY MM/DD/YY
NO. OF
DAYS IN
CONTRACT
YEAR
ANNUAL
BASE
SALARY*
FULL- TIME
PART -TIME
STEP/COLUMN
CLASS / ROW
POSITION TITLE
* Please verify the most recent licensed contract information within the last three years. If salary is prorated, list the published annual
amount for that step and column. Please attach applicable salary schedule.
Are additional monies included in the annual base salary entered above? _____Yes _____ No
If yes, how much additional funds did this employee receive beyond their base pay? $ _______________
For what reason was additional pay received (Example: Prop 301, TRI Monies, State Subsidies, etc.)? ____________________________________
For Nevada Public School Districts or Nevada Charter Schools Only
Unused sick leave:
_________Days/Hours
Years of experience in your district:
_________ Years
Was Nevada probation completed under NRS 391.31216? Yes_____ No_____
If a post-probationary employee, was an unsatisfactory evaluation issued during either or
both of the last two years of employment?
Yes_____ Which school year(s)? _______________________ No_____
Was contract year completed?
Yes_____ No_____
I certify that all information listed above is complete and accurate according to the ofcial records on le.
___________________________________ ___________________________________ _________________________________
Printed Name of Ofcial Representative Title Authorized Signature
___________________________________ ___________________________________ _________________________________
School Address Telephone Number Date
Completed form must be returned directly
by former school via:
U.S. Mail: Human Resources Division
Clark County School District
2832 East Flamingo Road
Las Vegas, NV 89121
Fax with Cover Sheet: (702) 387-0632
E-mail: contracting@nv.ccsd.net
GAC 4710.33 HR.LCS 4/2019
VERIFICATION OF SALARY PLACEMENT FORM
Licensed Contracting Services
Human Resources Division
(702) 799-2812
Ofcial School Seal or Stamp Required:
(If not available, attach business card or stationery.)
click to sign
signature
click to edit
![]()
