Verification of Experience Request or Employment (non-AB2534)

Verification of Experience Request or Employment (non-AB2534)

This form is to be used by all agencies requesting Verification of Experience of any Mt. Diablo Unified School District Current or Former Employees
Is this for AB 2534: Egregious Misconduct?*

YesNo
For AB2534, please use the following link:

https://mdusd.jotform.com/250794961408062
Are you submitting this Verification of Experience form as the employee or as an agency/organization on behalf of an employee?*

Employee requesting my own verificationAgency/organization requesting on behalf of an employee
Do you have a verification form provided?*

Yes, I have a form from my employer or requesting agencyNo, please prepare an official sealed letter of verification to be emailed or mailed
Does your verification request include confirmation of the employee’s:*

SalarySick–time balanceSalary and Sick-time balanceNo, salary and/or sick-time verification is not required
MDUSD Employment Status*

Current MDUSD EmployeeFormer/Historical EmployeeOther
Does the employee currently use a different name, or did they use a different name during their employment?*

No, the employee has always used the same nameYes, the employee currently uses a different nameYes, the employee used a different name at the time of employment
Employee Name (please provide the name used when employed with MDUSD):*

First NameLast Name
MDUSD Employee ID*
Employee Type*

ClassifiedCertificated
Name of Individual Requesting Verification*

First NameLast Name
Email of Requesting Individual/Agency*
example@example.com
Phone Number of Requesting Individual/Agency *
Please enter a valid phone number.
MAILING ADDRESS INFORMATION OF REQUESTING INDVIDUAL/AGENCY

This address will be used to mail the letter.
Address*
Address 2 (STE, APT, etc)
City*
State*
Zip Code*
Date Request Submitted*

MonthDayYear
Date
Date Needed By*

MonthDayYear
Date
Verification of Experience Form That Needs To Be Filled out By Mt. Diablo USD*

Cancelof
Should be Empty: