2016/04
Request for Change of Designated County/Multi-County Center
I verify that ___________________________________ SS# _____-_____-_______ has been hired by the
_______________________________________ County Board of Education/Multi-County Center
effective ___/____/______.
Therefore, I am requesting that ____________________________ County/Multi-County Center be
reflected as the County/Center of record in the Office of Educator Effectiveness and Licensure.
________________________________________
County/Multi-County Center Official (Print Name)
_________________________________________
County/Multi-County Center Official Signature
_________________________
Date
_________________________________________
Educator (Print Name)
_________________________________________
Educator signature
__________________________
Date
Please complete and submit to the Office of Educator Effectiveness and Licensure (OEEL).This form may
be faxed to 304-558-7843 or scanned and emailed to a staff member in the OEEL.