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ED 126 REV. 10/11

C.G.S. 10-145 C.G.S. 10-145d, P.A. 03-168

CONNECTICUT STATE DEPARTMENT OF EDUCATION Bureau of Educator Standards and Certification

P.O. Box 150471 ­ Room 243 Hartford, CT 06115-0471

www.ct.gov/sde

Use a separate form for EACH school district or approved nonpublic school in which you have served. PRINT all information in blue ink and in uppercase letters.

LAST NAME ­ ­ FIRST NAME ­ ­ MI

STATEMENT OF PROFESSIONAL EXPERIENCE

SOCIAL SECURITY NUMBER

BIRTH DATE (Month-Day-Year) ­ Required

The Superintendent's Office MUST Complete The Grid Below. (Applicants do NOT complete sections below this line.) (e.g., teacher, administrator, social worker, etc.)

Position Held

For middle/secondary teachers, indicate each subject taught.

Subject/Field

Grade Level

Certification Endorsement

Required for Position

FullTime (50% or more)

Check Below if:

PartTime (less than 50%)

From (Month/ Year)

Dates of Service

To (Month/ Year)

Adult Education

If the applicant served as an adult education teacher, indicate the number of hours served per school year.

# of hours/yr.

# of hours/yr.

# of hours/yr.

School Psychologist

If the applicant completed a school psychologist internship (not under contract), please check here.

Superintendent Attestation: Please check the appropriate box, sign and complete the school information below. The applicant named has served successfully in the above position(s) in our public or approved nonpublic schools. The applicant named has NOT served successfully in the above position(s) in our public or approved nonpublic schools.

Signature of Superintendent, Executive Director or Designee attesting to accuracy of information (Original Signature: No Signature Stamps Accepted) Typed or Printed Name of Person Signing Above Employing Agent City State Zip Code

Date

Title Telephone E-mail Address

Information on this application is subject to disclosure pursuant to the Freedom of Information Act.

Information

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