College Verification Form - Virginia Department Of Education printable pdf download

July 1, 2017

Virginia Department of Education

FOR OFFICE USE ONLY

Division of Teacher Education and Licensure

P. O. Box 2120

Richmond, VA 23218-2120

COLLEGE VERIFICATION FORM

The purpose of this form is to determine whether an applicant for licensure has completed a state-approved preparation

program at the undergraduate or graduate level. In these cases, the form must be completed by the appropriate

certification/licensure official of the college/university where the program has been completed. The completed form must be

submitted to this office by the applicant along with other items required for licensure or to the Virginia school administrator

with whom the applicant has accepted employment.

PART I

Social Security Number:

Date of Birth: (Month/Day/Year)

Last Name

First Name

Middle Name

Suffix (Jr., Sr., III)

Address (Street, City, State, Zip Code)

Name of Institution

Degree Earned

Date of Degree Conferral

PART II: Please check the appropriate response:

YES

By my signature, I certify that the applicant satisfactorily completed a state-approved preparation program

and completed endorsements (teaching areas, administration and supervision, or pupil personnel services) in

the following areas:

____________________________________________________________________

ENDORSEMENTS:

PART III: Student Teaching, Internship, and/or Practicum Experience:

Course Title: ________________________ Course Number: ________________________ Clock Hours: __________________________

A. High School grade (s): _____________________________________________________

(Do not include special education experience; use line C.)

B. Elementary grade (s): ______________________________________________________

(Do not include special education experience; use line C.)

C. Specific special education area(s)* and grade level (s)_____________________________________________________________________________

*Please specify the exact nature of the exceptional child (children) included in the student teaching/practicum experience.

D. Special subject area(s) (e.g., Art, Music, P.E.): ________________________________ Grade level (s):_____________________________

PART IV: To be completed by Virginia colleges and universities only:

If I am signing as a Virginia college or university representative, my signature below certifies that the individual has met the following

requirements checked below:

Child abuse and neglect recognition and intervention training and technology standards for instructional personnel;

Certification or training in emergency first aid, CPR, and the use of AED;

Dyslexia training; and

School counselors training (if applicable).

Requisite to compliance with the licensure regulations established by the Virginia Board of Education are the following conditions:

the applicant must be at least 18 years of age and must possess good moral character. By my signature, I certify on the basis of my

information and belief that the applicant possesses good moral character.

SIGNATURE:

____________________________________________________________

DATE: _______________________

NAME:

____________________________________________________________

TITLE:

____________________________________________________________

INSTITUTION:

____________________________________________________________

ADDRESS:

____________________________________________________________

PHONE NUMBER: __________________________________

EMAIL ADDRESS: ________________________________

College Verification Form - Virginia Department Of Education

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