Education General/teacher Cadet Experience Report Form For Michigan Interm Occupational Certificate
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1EDUCATION GENERAL/TEACHER CADET
Rev. 08/14
EXPERIENCE REPORT FORM FOR MICHIGAN
INTERM OCCUPATIONAL CERTIFICATE
Instructions:
When applying for an IOC for Education General CIP 13.0000, this form must be completed by the
Superintendent or Chief Official of the employing school district or school and submitted to W.M.U.
CANDIDATE IDENTIFIERS
(REQUIRED IDENTIFIER)
(SELECT ONE or MORE OPTIONAL IDENTIFIERS)
Last 4-digits of
PIC: ______________________________
Social Security #: _XXX-XX-___________
(available through Michigan Online Educator Certification System
)
Date of Birth: _________________________
W.M.U. Student ID/WIN #: ________________________
MOECS Application #: _________________
Name of School District
or School in Which
Candidate was Employed
School District’s/School’s Address:
TWO YEARS TEACHING EXPERIENCE REQUIRED FOR CIP 13.0000
This is to certify that _________________________________________________________________________________
(
first name)
(middle/maiden name)
(last name)
taught full-time (2 ½ clock hours or more a day) from ________________________ to __________________________
(
month)
(day)
(year)
(month)
(day)
(year)
in grade(s) _______________ and subject(s) _____________________________________________________________.
_____________________________________________________________________________
.
THIS CANDIDATE HAS AT LEAST ONE YEAR AS A HIGHLY EFFECTIVE TEACHER OR HAS
TENURE WITH YOUR SCHOOL SYSTEM:
YES/TRUE
______________________________________________________________
________________________________
Superintendent or Chief Official’s Signature
Date
______________________________________________________________
_______________________________
Name and Title (please type or print)
Area Code/Telephone Number
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