LAST TEA ID Number

FIRST

MI

TEACHER SERVICE RECORD

4 S!"##$ D+-'r+!' Or I(-'+'u'+#( .I(/+!&'e 0ub$+! #r 0r+,&'e1 5 2#-+'+#( He$/ 6 %e&r#3 E40er5 7 6#3 D&) Em05 8 N#5 D&)Em05 9 D&'e- #3 Ser,+!e Fr#m T# .&1 .b1 1 S'&'e S+!7 Le&,e 2r#8r&m S'&'e 2er-#(&$ Le&,e 2r#8r&m 2r+#r %e&r <&$&(!e .&1 .b1 .&1 .b1 .&1 .b1 .&1 .b1 .&1 .b1 .&1 .b1 .&1 .b1 .&1 .b1 .&1 .b1 .&1 .b1 E&r(e/ U-e/ E(/=#3=%e&r <&$&(!e 11 Au'"#r+9e/ S+8(&'ure: T+'$e: ; Or8&(+9&'+#( O33+!+&$ S'&m0

SIGNATURE OF TEACHER
1 S! "# #$ %e &r 2 S'&'e Or C#u('r) 3 C#u(') Or E*u+,&$e('

N#'e> I(-'ru!'+#(- #( <&!7

FIN 115

Instructions for completing FIN-115 (All columns must be completed unless otherwise indicated)
1. 2. 3. School Year State or Country County or E ui!alent -- Corresponds to the scholastic school year (e.g., 1997-98, etc.) employment is claimed. -- #nter state or territory o! $%A. #nter name o! !oreign nation i! applicable. -- #nter county or parish in $%A. &or 'epartment o! 'e!ense 'ependents( %chools (')''%) enter the names o! subterritories o! !oreign nations. ')''% %er*ice records must be completed by an o!!icial !rom the ational Archi*es and +ecords Administration ( A+A) in %t. ,ouis, -). (A blan. ser*ice record must be sent to/ A+A,C0+ 111 1innebago %treet, %t. ,ouis, -) 23118-4199). -- #nter name o! public school district or institution and name o! pri*ate school or institution. 5i*e su!!icient in!ormation in this column to identi!y the school !or accreditation purposes. (e.g. 0ublic or 0ri*ate). -- #nter position held (e.g., teacher, substitute, bus dri*er, etc.) -- #nter the number o! year(s) o! actual e"perience as o! %eptember 1 o! the school year indicated in column 1. ('o not include the additional year(s) !or career ladder, career and technology education wor. e"perience, or 6uali!ied teacher aide e"perience. Career and technology education wor. e"perience or 6uali!ied teacher aide e"perience must be recorded as a !ootnote on the ser*ice record). -- #nter percentage o! the school day employee was employed. &ull day is reported as 1778, one-hal! day is reported as 978, three-6uarters o! the day is reported as 798, etc. -- #nter the number o! days employed during the contractual year (:uly 1 thru :une 37). ;he days entered must not include the number o! days a person was doc.ed a !ull day(s pay. -- #nter the actual beginning and ending dates o! employment during the contractual year (:uly 1 thru :une 37). o more than one year o! e"perience can be shown on one line.

". 5. '.

School #istrict or Institution $osition %el& Years of E(perience

). +. ,.

* of #ay Employe& No. of #ays Employe& #ates of Ser!ice

1-. State .ea!e $rograms/ 0a1 State Sic2 .ea!e $rogram -- #nter state sic. lea*e in!ormation in this row < not re6uired !or pri*ate schools, colleges, and out-o!-state schools.

031 State $ersonal .ea!e $rogram -- #nter state personal lea*e in!ormation in this row (+e6uired !or Charter schools i! state days are o!!ered) < not re6uired !or pri*ate schools, colleges, and out-o!-state schools. ( ote/ ;his program was initiated in the1999-92 school year). 11. 4uthori5e& Signature6 7itle6 an& 8rgani5ation 8fficial Stamp -- ;he record must be *eri!ied by either signing each line o! the record separately (in in.) or by drawing a diagonal line and placing the signature diagonally across !rom the years o! e"perience. An authori=ed o!!icial o! the school system must sign the record. A rubber stamp signature may be used, in lieu o! the original signature, pro*ided the name o! the person appearing on the stamp is the same name designated by the school district to sign the ser*ice record. %uch o!!icial, i! not the superintendent o! the school, must ha*e been authori=ed to sign personnel records o! the institution by the go*erning board o! that institution. >n the case o! public schools, the board o! trustees is the go*erning body. ;he organi=ation(s o!!icial stamp must be included on the ser*ice record i! ser*ice !rom o*erseas is reported. &or public schools, colleges and uni*ersities, the country?s 'epartment o! #ducation is the organi=ation o!!icial stamp . >! ser*ice is reported !rom the $%, o!!icial stamp may be included depending on a*ailability. Note/ -- All ser*ice claimed !or salary increment purposes must be documented on this !orm or other similar document containing similar in!ormation. -- %er*ice records and any supporting documents must be complete in in.. -- 1hite out may not be used, any white out used on any document submitted will nulli!y the document.