ࡱ> |{ $Fbjbj Bb   GGGGG[[[8l[,*V9n[\(e)e)e)e)e)e)$,P/)]G55)GG4)###RGG(#(##&0'[}K]"[ &()0,*',0 00'0'&0GV',#))!n,*0 : Wisconsin Department of Public Instruction PDP VERIFICATION FORM PI-PDP-2 (Rev. 8-09)INSTRUCTIONS TO EDUCATOR: Complete Part I and submit to your PDP Team for signature. INSTRUCTIONS TO PDP TEAM MEMBER: Complete Part II in the appropriate team member section and return to educator.Professional Development Plan (PDP) forms available at: http://dpi.wi.gov/tepdl/pdp.htmlI. EDUCATOR INFORMATIONEducator Name  FORMTEXT      Educator E-Mail Address  FORMTEXT      Educator File No.*  FORMTEXT      LICENSURE CATEGORY:  FORMCHECKBOX  Teacher  FORMCHECKBOX  Administrator  FORMCHECKBOX  Pupil ServicesDate PDP Submitted for Verification  FORMTEXT      PRESENT LICENSURE STAGE:  FORMCHECKBOX  Initial Educator  FORMCHECKBOX  Professional Educator  FORMCHECKBOX  Master EducatorI HEREBY CERTIFY THAT, by my signature below, under penalty of perjury, that the information submitted by me in this form is true. I am aware that submitting false information in connection with this process may result in non-approval and/or non-renewal of a license and may subject me to civil or criminal penalties. Educator Signature (Date Signed II. PDP TEAM MEMBER INFORMATIONTeam Member Name  FORMTEXT      Team Member E-Mail Address  FORMTEXT      Date Trained As a team member  FORMTEXT      Educator File No.*  FORMTEXT      Representing Check one  FORMCHECKBOX  Teacher  FORMCHECKBOX  Pupil Services  FORMCHECKBOX  Administrator  FORMCHECKBOX  IHECheck One  FORMCHECKBOX  PDP Verified  FORMCHECKBOX  Not VerifiedI HEREBY AFFIRM, by my signature, that the information provided is true and correct.Signature (Date Signed Team Member Name  FORMTEXT      Team Member E-Mail Address  FORMTEXT      Date Trained As a team member  FORMTEXT      Educator File No.*  FORMTEXT      Representing Check one  FORMCHECKBOX  Teacher  FORMCHECKBOX  Pupil Services  FORMCHECKBOX  Administrato-DTWXYefs  ! @ C F W Y { | } ᖏ{s{hsXjh\PJUmHnHujh\Ujh\Uh\hEhQh,pOJQJ hLh,phH; hQ5hQ5hLhu hu5hFhBFOJQJhFOJQJh%)OJQJh)JOJQJh"'hQ5CJOJQJaJhQOJQJhQCJOJQJjh)JOJQJU"-DY ! { QF P$IfgdH;skd<$$IfP4+F0*    4 Paf4p$x$Ifa$gdw$ $If^a$gdu d$If $Ifgd,p{ | } 1kdC$$IfP4F 0* P    4 Paf4p dP$If=kd$$IfP40**4 Paf4ytiyp  > f Xekdy$$IfP4FxJ0*x P    4 Paf4ytw$$If^a$gdw $$Ifa$gd\ $Ifgd-m $Ifgd $If^gdw$If > @ T V X b d f x    0 2 4 P R T p r wshs]jh\Ujh\Uhtjnh\U ht5 h\5 hEh\CJOJQJ^JaJjh\UmHnHujh\Uh%)0jh h\OJPJQJU^JmHnHujh htU h h\jh h\Uh\jh\U$r t       + , - > ? @ N O P f g h v w x ~sodoYj h\Uj h\Uhtj}h\U ht5 h\5,jhthtCJOJPJUmHnHu'jLhthtCJOJQJUhthtCJOJQJ!jhthtCJOJQJUh\OJQJ^JaJhEh\OJQJ^JaJ hSh\h\jh\U   q^  (x$IfgdtRkd$$IfP4k0J0*J P4 Paf4ytw  $If^gdw  (x$Ifgd\$  Z($Ifa$gdt k l   BDXZ\fhj칵쭠rkc_Tcj$htUhtjhtU h-dh{'(jh-dh{'PJUaJmHnHuj>$h-dh{'UaJh-dh{'aJjh-dh{'UaJh-dh{'5h~hX4 h\hQ5B*CJ aJ ph hththw jh{*CJaJh{*h hQ hQ5hL hLhL zqbq  $IfgdK; $Ifgdw<kd!$$IfP4 0*0*P4 Paf4($If?kdk!$$IfP40*0*P4 Paf4ytw  dd$Ifgd-d Wdgd-mRkdU"$$IfP40!0*!pP4 Paf4yt-m BjJD>5 $Ifgd-m$If$Ifkd #$$IfeFU 7*N N   t0    44 ealpyt"(*,>RThjlvx| ͯݫݠ͒ݎ~s~~h~~]jn(h22WUj'h22WUj.'h22WUjh22WUh-dh22W6h22Wjh{'UmHnHuj%h{'Uh%)$jh-dh{'PJUmHnHuj%h{'Ujh{'Uh-dh{'6h{'h-dh{'aJjhtUjhtUmHnHu$,Rz $$Ifa$gd-d$If$$Ifa$gdxr $If^gd-mz|FE:" ^6ZV$If^Vgd-m $Ifgd-dkd&$$Ife0\U !7*N @ 2 p t044 ealp(ytw !01?@APQ_`abnop~ª™™vdvVKh-dh22WCJaJ jh-dh22WCJaJ#h22Wh22W5CJOJQJ^JaJh-dh22WOJQJ/jB*h-dh22WCJOJQJU^JaJ h22Wh22WCJOJQJ^JaJ/j)h-dh22WCJOJQJU^JaJ h-dh22WCJOJQJ^JaJ)jh-dh22WCJOJQJU^JaJj )h22WUh22Wjh22WUFPoaP<($If^gd22Wkd*$$Ife0!7*!p t044 ealpytw $Ifgd22W ($Ifgdww $Ifgd-m $Ifgdw $Ifgdwikd+$$Ife7*0* t044 ealyt,p  DFZ\^hjló̞×rnf^nS^j-hK;UjhK;Uh-dhK;6hK;jhtUmHnHuj-htUhtjhtU h-dhK;(jh-dhK;PJUaJmHnHuj-h-dhK;UaJh-dhK;aJjh-dhK;UaJh-dhK;5h\hQB*aJphh-dh22WOJQJ h22Wh22WDluoi`SE$$Ifa$gdxr $If^gd-m $Ifgdw$If$If Wdgd-m~kdS,$$Ifex0!7*!w t044 ealyt-m  :NPlnp>>>">$>&>D>F>m)jh-dh22WCJOJQJU^JaJj1h22WUUj1h22WUjj0h22WUj/h22WUjh22WUh-dh22W6h22WjhK;UmHnHujx.hK;Uh%)hK;jhK;U$jh-dhK;PJUmHnHu% NOD $Ifgd-dkd.$$Ifl0\N !0*N @ 2 p t044 lalytw$If$Ifr  FORMCHECKBOX  IHECheck One  FORMCHECKBOX  PDP Verified  FORMCHECKBOX  Not VerifiedI HEREBY AFFIRM, by my signature, that the information provided is true and correct.Signature (Date Signed Team Member Name  FORMTEXT      Team Member E-Mail Address  FORMTEXT      Date Trained As a team member  FORMTEXT      Educator File No.*  FORMTEXT      Representing Check one  FORMCHECKBOX  Teacher  FORMCHECKBOX  Pupil Services  FORMCHECKBOX  Administrator  FORMCHECKBOX  IHECheck One  FORMCHECKBOX  PDP Verified  FORMCHECKBOX  Not VerifiedI HEREBY AFFIRM, by my signature, that the information provided is true and correct.Signature (Date SignedNote to Applicant: Submit this completed PDP Verification Form with your license renewal application and fee to DPI. 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PDP formsCatherine.Cullen@dpi.wi.govCullen, Catherine L. 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