Hicksville Exempted Village Schools
Professional Development Activity Verification
Yellow Form

Name:

Social Security Number:

Please indicate the type of activity and follow the directions below:

	College Coursework Attach a copy of your transcript or official grade report to this form.
	Approved Workshop/Seminar/Conference(Non-Local Provider): Attach one or more of the following -- a. CEU form from the provider b. Certificate of Completion from the provider c. Presenter/Facilitator signature on program agenda d. Signature of administrator or supervisor
	Other Approved Local Activities: Attach one or more of the following -- a. Signature of administrator or supervisor b. Final product, or copy (if applicable) c. Verification of staff presentation (if applicable)

Submit this form to your LPDC representative at the completion of your activity and to receive credit for your Professional Development.

Title of Course or Professional Development Activity:

Fill in one:	# of Contact Hours earned
	# of Semester Hours earned
	# of Quarter Hours earned

Date the Course /Conference/Activity was completed:

To print, click the SUBMIT button below, and then print the page that appears.