Form Ot 37 – Fill Out and Use This PDF

The University of the State of New York

THE STATE EDUCATION DEPARTMENT

Office of Teaching Initiatives, Room 5N-EB

89 Washington Avenue

Albany, New York 12234

www.highered.nysed.gov/tcert

Verification of Experience for Permanent/Professional Certificate

Check One: ____	Permanent Certificate in	_______________________________________________________
		(Certificate Title)
____	Professional Certificate in	_______________________________________________________
		(Certificate Title)

In response to your inquiry regarding Permanent/Professional certification in the above title, your application cannot be processed until the status of the required experience has been verified. For Permanent certification, Commissioner's Regulations require two years of paid work experience in a public or approved non- public/independent school. For Professional certification, Commissioner's Regulations require three years of paid work experience in a public or approved non- public/independent school. To have your experience considered for this requirement, please supply the information as noted below and return this form to the above address.

Name: __________________________________________________________________________________________

(First)(Middle) (Maiden)(Last)

Address: _________________________________________________________________________________________

(Number)		(Street)		(Apartment)
__________________________________________________________________________________________
(City)			(State)	(Zip Code)
Date of Birth: _________/_______/__________			Social Security Number: _______/_____/________
(MM)	(DD)	(YYYY)

Select 1 or 2:

_____ 1. The candidate named above served as a full-time teacher* of _______________________________________

			(Subject)
___________________	FROM: ___________/______/________ to ________/______/_______
(Grade Level)	(MM)	(DD)	(YYYY)	(MM)	(DD)	(YYYY)

At ________________________________________________________________________________________

(Name of School)
Verified By:
_________________________________________	_____________________________________________
(Print name of Administrator)	(Signature of Administrator)
_________________________________________	_____________________________________________
(Administrative Title**)	(Date)

__________________________________________________________________________________________

(Name of School)

__________________________________________________________________________________________

(Address of School)

*Experience as a teaching assistant, aide, or paraprofessional is not applicable.

**Signature of the superintendent of schools, community superintendent or borough high school superintendent is required. If experience was earned in a non-public/independent school, the chief school officer's signature is required.

OT 37 (Rev. 11/2009)

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_____ 2. You listed on your application experience at __________________________________________________

We have no record that this a NYS public school or an approved non-public/independent school. Therefore, please attach the following:

_____ (a) Photocopy of day care center permit issued by New York State Department of Social Services

or New York City Department of Health.

_____ (b) Verification of nursery school/kindergarten registration issued by New York State Education

Department, Bureau of Child Development and Parent Education.

_____ (c) Verification of private special education school approval issued by New York State Education

Department, Office of Education of Children with Handicapping Conditions.

_____ (d) Other _______________________________________________________________________

OT 37 (Rev. 11/2009)

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