ࡱ> QTP_  bjbj(( =MB8\B8\FTTThhh8Dh1:::$g tT:":::p8:<`4d01 <  T::::::::::1:::: :::::::::> :  Last Name First Name Middle Name Maiden Name  site (e.g., Gornto, Blue Ridge Community College, etc.): ______________________________________________ Home Address Home Telephone # () Social Security/UIN# School Division School Name School Address School Telephone # ()  School FAX # School Principals Name Participant e-mail address Grade level(s) currently assigned :____________ Disability(s) currently working with ___LD___ED___ID ___ autism ___TBI ___OHI ___multiple disabilities ___developmental delay I do _____ do not _____ have a valid special education provisional license. I verify that I am employed in the above school division/program and am still eligible for the CSEEP/PPET program Signature of Teacher Date As a representative of (school division/state operated program), I confirm that the above-mentioned person is employed by the school division/program in the capacity stated above. Print name of principal/designee Signature of principal/designee Date     The Commonwealth Special Education Endorsement Programs Employer Verification Form This form is required annually for grant participants. Your principal or a designee must verify your employment with his/her signature below. No grant funds will be credited to your account until this form has been successfully submitted. You may return this form by fax to: 757-683-4129 or you may scan it and email it to  HYPERLINK "mailto:cseep@odu.edu" cseep@odu.edu is an equal opportunity, affirmative action institution. Please mail applications to: CSEEP Grant Office, Child Study Center, Room 116, , Norfolk, VA 23529. 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