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PBS Station Trainers - EekoWorld

<<PBS Station Trainers

Certificate of Participation

I certify that the person named below has successfully completed a staff development activity sponsored by the Elementary Education Division.

Name of Instructor or Other Person Directly Supervising Activity:

_____________________________

Sponsoring Section:

_____________________________

Address:   6366 Mail Service Center
Raleigh, NC 27699-6366

Telephone:  919.807.3932

Signed:_______________________

Title: _________________________________________

Division Director:  _________________________________ 

Date:    __________________

DATA ON PARTICIPANT

School: _______________________                             

Date of Birth: ____________________

SSN: _____________________

Cert. Exp. Date: __________________

Name:______________________________________           

             Last      First       Middle        Maiden

Address:_______________________

                        Street or P.O. Box       

City: ________________________  

State: _____________________    Zip: ____________

Note:  If renewal credit is desired, you should submit this form to your employing Superintendent or Headmaster; or retain this form for your record as part of the documentation when you have completed requirements for the renewal/reinstatement of your certificate.