This form should be submitted as part of your certification application to the respective authority. You can send it via email at certifications@maryland.gov, or fax it to 410-767-0386. Paper submissions can be mailed to Division of Educator Certification, 200 West Baltimore St., Baltimore, MD 21201. Make sure to keep a copy for your records. Prioritize submitting your application before any stated deadlines to ensure timely processing.

For the 2024-2025 cycle, ensure to submit this form before January 31 for early applications. Standard processing will continue until June 15. Late applications may not be processed until the next cycle.

The purpose of this form is to verify the educational experience of candidates seeking certification. It confirms employment details such as service dates and performance ratings that are critical for evaluation. Completing this form accurately ensures the applicant's qualifications are properly assessed.

• 1. First Name: The applicant's first name.
• 2. Last Name: The applicant's last name.
• 3. Middle Initial: The applicant's middle initial.
• 4. Maiden Name: The applicant's maiden name, if applicable.
• 5. Last 4 Digits of Social Security Number: Partial identification number for verification.
• 6. Date of Birth: The applicant's date of birth.
• 7. Address: The applicant's current address.
• 8. City: City of residence.
• 9. State: State of residence.
• 10. Zip Code: Postal code of the applicant's address.
• 11. Email: Contact email address.
• 12. Home Phone: Home phone number.
• 13. Mobile Phone: Mobile phone number.
• 14. Signature of Applicant: Applicant's signature for verification.
• 15. Date: The date of signature.
• 16. Employer: Name of the employer for employment verification.
• 17. School/School District: The name of the school or district where employed.
• 18. State (of School): State where the school or school district is located.
• 19. Dates of Service (From - To): Start and end dates of employment.
• 20. FT/PT: Indicates if the employment was full-time or part-time.
• 21. Performance Rating: Performance appraisal by the employer.
• 22. Subject Taught: Main subject taught by the applicant.
• 23. Grade(s) Taught: The grade levels at which the applicant taught.
• 24. Printed Name of Authorized Official: Name of the official validating the employment.
• 25. Signature of Authorized Official: Signature of the validating official.
• 26. Date (of Signature): Date the validating signature was provided.
• 27. Title: Title of the validating official.
• 28. Phone: Contact number of the validating official.
• 29. E-Mail: Email address of the validating official.

Failure to submit this form may delay your certification process. Incomplete or missing information can result in disqualification. Timely completion and submission are crucial for successful application.

• Delays in Certification: Missing submissions can lead to significant delays in obtaining your certification.
• Increased Scrutiny: Incomplete forms may be subjected to additional review processes.
• Risk of Disqualification: Failure to provide accurate information may disqualify candidates from certification.

• 1. Certification Applications: Required for individuals applying for teaching certification.
• 2. Employer Verification: Used by school districts to validate employee claims.
• 3. Nonpublic/Private School Applications: Necessary for accrediting bodies evaluating applications.