SAINT LUCIE PUBLIC SCHOOLS
ST. LUCIE COUNTY USE ONLY
HUMAN RESOURCES DEPARTMENT
YEARS CREDIT GIVEN:
4204 Okeechobee Road, Fort Pierce, FL 34947
SALARY ADJUSTMENT MADE:
Telephone: 772-429-7508 Fax: 772-429-7510 www.stlucieschools.org
EMPLOYMENT VERIFICATION
EMPLOYEE COMPLETE THIS SECTION:
INSTRUCTIONS: Please type or print all information. Sign and date.
EMPLOYEE'S NAME (INCLUDE ANY FORMER NAME AT TIME OF EMPLOYMENT)
TO (NAME AND ADDRESS OF FORMER EMPLOYER)
*SOCIAL SECURITY NUMBER
AUTHORIZATION TO RELEASE INFORMATION
I understand that it is my responsibility to forward the Employment Verification Form to each of my previous
employer(s). I hereby authorize the release of Information from my payroll/personnel records to The school Board of
St. Lucie County, Florida.
EMPLOYEE'S SIGNATURE
DATE
DISTRICT / AGENCY COMPLETE THIS SECTION:
INSTRUCTIONS: Please type or print. All information requested on this form is necessary. Salary level will be determined by creditable years of experience. Do not list
substitute teaching experience. Indicate if position was full-time or part-time. Your School Board seal or notarization is required. Your promptness in returning this
directly to the address above is appreciated. Credit for a year of service is given only when the period of service exceeds one-half of an actual annual contractual
period by at least one day and experience is deemed satisfactory by verifying district/educational institution.
Satisfactory
Contract Number
School Year
Is School Accredited? Yes or No
FullPartPublic or
Positions Held
Grade
Performance
List Each Year
Days in of Days
If yes, list name of accrediting
Time
Time
Private (i.e. Teacher, Assistant Principal, etc.) Level
Evaluation? Yes or No Agency
Separately
School
Taught
Example:
Example:
Example:
Example: Example:
Example:
Example:
Example:
Example:
Example
1999
2000
196
196
X
Public
Teacher
4
Yes
Yes - SACS
2000
2001
196
174
X
Public
Teacher
4
Yes
Yes - SACS
Continued on back of form.
Was this employee ever disciplined?
Was this employee ever referred to the state licensing/certifying authority? Circle One: YES
NO
Circle One: YES
NO
Was this employee ever terminated? Circle One: YES
NO
IN WITNESS WHEREOF, I have hereto affixed my name and have caused the official seal or notarization of
District or Agency to be affixed this __________ day of _____________________ 20______
AFFIX
SEAL
_______________________________________________
SIGNATURE OF AUTHORIZED SCHOOL OFFICIAL
_______________________________
PRINTED NAME
_______________________
TITLE
__________________
PHONE NUMBER
*Social security numbers are collected, and will only be used, in order to conduct background checks, and, once hired, to process payroll/personnel action, employment benefits, and retirement benefits.
PER0007 Rev. 10/2015
Page 1 of 2
School Year
List Each Year
Separately
Contract
Days in
School
Number
of Days
Taught
Example:
Example:
Example:
196
196
1999
2000
FullTime
PartTime
Public or
Positions Held
Private (i.e. Teacher, Assistant Principal, etc.)
Example: Example: Example:
X
Public
Grade
Level
Satisfactory
Is School Accredited? Yes or No
Performance
If yes, list name of accrediting
Evaluation? Yes Agency
or No
Example:
Example:
Example:
Example:
Teacher
4
Yes
Yes - SACS
PER0007 Rev. 10/2015
Page 2 of 2