| A | B | C | D | E | F | G | H | I | J | |
|---|---|---|---|---|---|---|---|---|---|---|
1 | ILLINOIS STATE BOARD OF EDUCATION | |||||||||
2 | Educator Licensure Division | |||||||||
3 | 100 North First Street, S-306 | |||||||||
4 | Springfield, Illinois 62777-0001 | |||||||||
5 | ||||||||||
6 | EVIDENCE OF COMPLETION FOR PROFESSIONAL DEVELOPMENT | |||||||||
7 | This is to certify that the undersigned has completed the professional development activity described herein and that the provider is approved by the State Superintendent of Education at the time of completion. This form serves as evidence to verify participation in this professional development activity and must be maintained for a period of six (6) years by the licensee and produced if requested as part of an audit. | |||||||||
8 | ||||||||||
9 | IMPORTANT: THE LICENSEE MUST ENTER THIS ACTIVITY INTO THE EDUCATOR LICENSURE INFORMATION SYSTEM (ELIS) BEFORE THE END OF HIS/HER CURRENT RENEWAL CYCLE OR FORFEIT ANY PROFESSIONAL DEVELOPMENT CREDIT FOR THIS ACTIVITY. | |||||||||
10 | ||||||||||
11 | NAME OF PARTICIPANT (Last, First, Middle Initial) | |||||||||
12 | <<Last Name>>, <<First Name>> <<Middle Initial>> | |||||||||
13 | TITLE OF PROFESSIONAL DEVELOPMENT | |||||||||
14 | <<Which training did you complete?>> | |||||||||
15 | DATE(S) OF ACTIVITY | |||||||||
16 | 11/13/2019 | |||||||||
17 | LOCATION (Name of Facility, City, State) | |||||||||
18 | Eureka CUSD #140, Eureka, IL | |||||||||
19 | NAME OF APPROVED PROVIDER | REGION, COUNTY, DISTRICT, TYPE CODE | ||||||||
20 | Eureka CUSD #140 | 53, Woodford, Eureka CUSD 140 | ||||||||
21 | NAME OF PROVIDER (If authorized by the approved provider) | |||||||||
22 | * | |||||||||
23 | NAME OF PRESENTER | |||||||||
24 | Tyler Breitbarth | |||||||||
25 | NUMBER OF PROFESSIONAL DEVELOPMENT HOURS | |||||||||
26 | 1.0 | |||||||||
27 | ||||||||||
28 | ||||||||||
29 | My Signature | 11/13/2019 | ||||||||
30 | ||||||||||
31 | Signature of Approved Provider's Representative | Date | ||||||||
32 | ||||||||||
33 | ||||||||||
34 | ||||||||||
35 | Signature of Participant | Date | ||||||||
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