OUT OF COUNTY VERIFICATION OF YEAR(S) OF EXPERIENCE

OF NON ATHLETIC SUPPLEMENTAL PAY FORM

______________________________________________ _______________________
(Name) (Social Security Number)

_____________________________________ is currently employed by the School Board of Orange County. He/She

has indicated previous NON ATHLETIC SUPPLEMENTAL PAY with your school system/institution. To determine the
correct amount of SUPPLEMENTAL PAY, verification of previous non athletic experience is required by the district.

School State County School/Institution Type of Beginning Ending

Year Pay Work Date Work Date

___________________________________ ________________________________
(Signature of Verifying Official) (Title of Verifying Official)

___________________________________ ________________________________
(Name of School or Institution) (Stamp or Seal of School or Institution)

__________________________________________ _____________________________________
(Phone Number ) (Email)

The foregoing instrument was acknowledge before me this

_____________________ by __________________________
(Date) (name of person acknowledged)
Who is personally known to me or who has produced _________________________________________ as identification.

___________________________________
Signarure of Notary Public

Notary stamp with name, commission number and expiration date

I appreciate your cooperation and assistance in providing the information requested and returning the completed form
to my office.
Return to: Lonnie Flores
Senior Administratior,
Athletics and Activities
Orange County Public Schools
445 W. Amelia Street Orlando,
FL 32801-1127