5-Year-Cerification-Renewal-Request-Form

5-Year-Cerification-Renewal-Request-Form









Renewal Year: ____________
Employee ID #: ___________

5- YEAR CERTIFICATION RENEWAL REQUEST FORM
Name (please print)______________________________________ Date ____________________________
Job Title _____________________________

Supervisor (please print) ___________________________
Part-Time Employee: (Check current status)

Full-Time Employee: (Check current status)

Type of Activity-Refer to the District Certification Renewal Plan for an explanation and information about credit limits
Educational Activities- Please mark the box in relation to the activity type completed
Activity
Code

Verification of Activity
Documentation Needed

Activity Description

IA

Graduate, Undergraduate, Associate Degree, or Technical Diploma
Course

IB

Job-related Workshops, Conferences, Seminars, or Continuing
Education Courses

IC
ID
IE

Teaching (credit courses) – Non-instructional & instructional personnel
Job Enrichment
Teaching/facilitating district activities for certification course content

IF

Curriculum/course development

IG

District requirement courses for initial 5-year certification

Official transcript
Copy of program/agenda & registration
confirmation or travel report
Or
Certificate of completion
Signed documentation of activity
Signed documentation of activity
Signed documentation of activity
Course outcome summary or
documentation showing the changes
Certificate of completion & prior approval
from supervisor

Occupational Activities- Please mark the box in relation to the activity type completed
Activity
Verification of Activity
Code
Activity Description
Documentation Needed
IIA

Occupational Experience

IIB

Consulting (business, industry, or educational facility on a voluntary or
paid basis directly related to your assignment, but not part of your job)

Verification of occupational experience
form OR Self verification form
Copies of time cards or other signed
documentation of activity.

Community & Professional Activities- Please mark the box in relation to the activity type completed
Activity
Verification of Activity
Code
Activity Description
Documentation Needed
Copy of agenda showing you as presenter
Formal Presentation
IIIA
Presentation to Certification Officer
Literary Accomplishment
IIIB
Signed documentation of activity
College In-house Committee Participation
IIIC
Written verification from officer or chair
Leadership position/role
IIID
Signed documentation of activity
Other professional development activities
IIIE
Course Title:________________________

Course No.: __________

College/University: ___________________

Activity Information: (Describe the activity, attach supportive materials, and explain why this activity should qualify)

Activity Hours: _______

Starting Date: ________

Requestor Signature: ___________________________

Semester Credits: ______

Ending Date: ________

Supervisor Signature:___________________________

Approved

Comments: ___________________________________________________________________________

Certification Officer: ___________________________________

Date:

___________________

Western Technical College, Certification, A-115, P.O. Box C-0908, La Crosse, WI 54602-0908 Phone: 608.789-6253 or 608.789-6233

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