Pde 338 V Form – Fill Out and Use This PDF

VERIFICATION OF EXPERIENCE FORM PDE 338 V

USE ONE FORM FOR EACH EMPLOYER

(Refer to instructions included with this form)

APPLICANTS: Please note the following information in regard to your Social Security Number (SSN) DATA REQUIRED BY THE FEDERAL PRIVACY ACT (5 U.S.C. Section 552a note) AUTHORITY: 24 P.S. Section 1224.

PURPOSE(S): To be used for (1) registration and maintenance of records of all certificated persons as having met qualifications for teaching, (2) identification and collection of criminal/disciplinary records for certified educators and candidates for certification and (3) provision of certification data to authorized personnel and agencies. DISCLOSURE: Mandatory. Failure to disclose will prevent further processing of the application.

SECTION I – APPLICANT INFORMATION (please print or type)

1. Last Name	First Name	Middle Initial	2.	Social Security Number

SECTION II-PROFESSIONAL EDUCATOR EXPERIENCE (to be completed by employer)

Beginning Date	Ending Date	Full-Time/	If Part-Time,	Position Held (e.g.	If Teacher, indicate
of Service	of Service	Part-Time	total hours	Teacher, Counselor,	subject and grade
(month, day, year)	(month, day, year)		worked per	Supervisor, Principal,
			week	Superintendent)

□Full-Time

□Part-Time

□Full-Time

□Part-Time

□Full-Time

□Part -Time

□Full-Time

□Part-Time

SECTION III-SCHOOL DISTRICT/INSTITUTION INFORMATION

3.
_____________________________________________________			____________________________________
School Address			City, State and Zip Code
__________________________	__________	_____________________________________________________
Telephone Number	Extension		Email address of contact person

SECTION IV-AFFIDAVIT

I verify that this record omits leave of absence periods and that all information is complete and correct according to the official records of the designated school district or institution.

_____________________________________________________	________________________	________________
Signature of Superintendent or Designee	Title	Date
		PDE 338V (Revised 11/08)

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VERIFICATION OF EXPERIENCE FORM PDE 338 V

PRINT WITH DARK BLUE OR BLACK INK

SECTION I: Applicant Information

1.Print or type your Last Name, First Name, Middle Initial, and Social Security Number.

2.Send a separate copy of this form and instruction sheet to each present or former employer. You may photocopy this form as needed.

3.The PDE 338 V form is an important part of your application packet. The form verifies your professional employment and may qualify you for certification.

After this form is completed by the employer it should be returned to you. Check the information documented on 338 V form for accuracy and completeness before adding it to your application packet.

4.In your application packet, include photocopies of certificates/licensures held during the entire time frame in which the teaching experience documented on the 338 V Form occurred.

SECTION II: Professional Educator Experience

(Section II must be completed by the employer- not the applicant)

1.All requested information must be supplied. Please note that Beginning and Ending Dates must include the month, day, and year.

2.Indicate whether the employment was full-time or part-time by checking either the “full-time” or “part-time” box. If the employment was part-time, enter the total hours worked per week.

3.Print the position held during the dates of employment listed. Please note, if the applicant has held more that one position in the district or institution, a separate entry must be made for each position.

4.If the position held was “teacher,” indicate the academic subject and grade level taught. Please note, if the applicant has held teaching positions in different subject and grade levels within the district or institution, a separate entry must be made for each teaching position.

SECTION III: School District/Institution Information

(Section III must be completed by the employer- not the applicant)

1.Print the name of the district or institution.

2.Indicate whether the entity is public or private by checking the “public” or “private” box provided.

3.Print the address of the district or institution and list a telephone number and/or Email address of the designated contact person.

SECTION IV: Affidavit

(Section IV must be completed by the District/Institution Superintendent or Designee.)

1.Verify that the employment information documented on the PDE 338 V Form is correct by signing and dating the application.

2.Return the PDE 338 V form to the applicant. Do not return the form to the Bureau of School Leadership & Teacher Quality.

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