CONTINUING EDUCATION CLOCK HOUR REQUEST INSERVICE REGISTRATION Use this form to verify your attendance at an approved clock hour offering outlined in Section II below.
SECTION I – PARTICIPANT INFORMATION Legal Name (Last, First, M.I.) Classified Certificated Former Name Your School Location Current Assignment Date of Birth WA Certificate No (Optional) Female Male Home address (street, city, state, zip code) Home Phone: ( ) Work Phone: ( ) SECTION II – INSERVICE INFORMATION Title of Inservice Instructor’s Name Maximum Clock Hours Available First Date of Inservice: Last Date of Inservice: Sponsoring Provider Name (Agency Granting Clock Hours) & Address Everett ...
Hours indicated ...
Allowed
Microsoft Office Word (.doc, .dot) - application/msword
... 
