PSOB EEC VERIFICATION OF WORK EXPERIENCE OR PRACTICUM FORM

EEC VERIFICATION OF WORK EXPERIENCE OR PRACTICUM FORM
This form is required when applying for a Professional Certification with the Department of Early Education and Care (EEC The applicant’s current/former work supervisor should complete the form and then returned it to the applicant for inclusion in their certification application.
Center Details
This is where practicum/work experience was completed
Center/School Name*
Center EEC Program Number (if applicable): P
Find your P number at childcare.mass.gov/findchildcare
Center College/University Affiliation (if applicable)
Center/School Address*
Applicant Details
Applicant Name*
Applicant Title/Position*
From*

MonthDayYear
Date
To*

MonthDayYear
Date
Total hours applicant worked
Age groups worked with (check all that apply)*

Infant/Toddler (Ages 0 months to age 2.9)Preschool (Age 3 to age 5)Mixed Toddler/Preschool (Age 15 months to age 5)Preschool/School Age (Age 3to age 6)Special Needs? If yes, list ages:
Special Needs? If yes, list ages
Supervisor Details
Supervisor Name*
Supervisor Title*
Supervisor EEC Certificate # or DESE Certificate # (if applicable)
Supervisor Telephone*
Supervisor Email Address*
example@example.com
Attestation by Supervisor
I attest, to the best of my knowledge, that all information contained herein is true and accurate.
Printed Supervisor Name*
Signature*

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Date*

MonthDayYear
Date
PLEASE RETURN COMPLETED AND SIGNED FORM TO APPLICANT
Should be Empty:

EEC VERIFICATION OF WORK EXPERIENCE OR PRACTICUM FORM