DoDEA Form 5013 Department of Defense Education Activity (DoDEA) Schools

DEPARTMENT OF DEFENSE EDUCATION ACTIVITY (DoDEA) SCHOOLS
VERIFICATION OF PROFESSIONAL EDUCATOR EMPLOYMENT
FOR SALARY RATING PURPOSES

OMB No. 0704-0370
OMB approval expires

The public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 1155 Defense
Pentagon, Washington, DC 20301-1155 (0704-0370). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with
a collection of information if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO REQUESTER IN A SEALED
ENVELOPE.

PRIVACY ACT STATEMENT
AUTHORITY: 10 USC, Section 2164; 20 USC, Sections 902 and 903; and EO 9397.
PRINCIPAL PURPOSE(S): Section I of this form provides your consent to obtain personal information from your former employer about your
employment. The information you supply, and that the former employer supplies in Section II will be used to verify your employment history to
determine creditable previous experience for pay setting purposes.
ROUTINE USE(S): Disclosure of germane information within the Department of Defense is authorized upon a demonstrated "need to know" to
perform an official duty. Routine disclosures of relevant and necessary information are authorized to agencies outside of the DoD by DoD Privacy Act
Systems Notices, which may be found at http://www.defenselink.mil/privacy/notices/osd.
DISCLOSURE: Your disclosure of the information requested in Section I of this form is voluntary. However, failure to complete or delay in receiving
the form may delay the processing of the applicant's application for employment or result in delay in receiving correct pay.

SECTION I - APPLICANT DATA
1. NAME (Last, First, Middle Initial)

2. SSN

3. FORMER SCHOOL/PLACE OF EMPLOYMENT

4. POSITION TITLE (Teacher, Counselor, Administrator, etc.)
6. ACADEMIC LEVEL (X one)
a. ELEMENTARY

5. FORMER SCHOOL/PLACE OF EMPLOYMENT ADDRESS
(Street, City, State, and Zip Code)

c. SENIOR HIGH
d. VOCATIONAL HIGH

b. JUNIOR HIGH
7. SIGNATURE OF APPLICANT

e. COLLEGE
8. DATE SIGNED (YYYYMMDD)

D R A F T
SECTION II - EMPLOYMENT DATA

The above named individual is an applicant, or has been selected for employment with the Department of Defense Education Activity (DoDEA)
Schools. The data you provide will be used to establish the pay for the above named person. The information you provide, including identity, will be
disclosed to the above named person, and to other Federal, State and local agencies, at his or her request, or as otherwise authorized by the Privacy
Act of 1974, as amended, 5 U.S.C. 552a. Your completion of this form is voluntary. However, delay or failure to complete the form may delay the
processing of the applicant's application for employment.
If employee was paid for the entire month at the beginning and end of service, use those dates instead of the dates when school was in session. If
there was a break in service, indicate each period of employment separately. It is necessary that we have the specific day as well as the month and
year. Your assistance in completing this form is appreciated. Please return it as soon as possible to the applicant in a sealed envelope.
9. DATES OF EMPLOYMENT
a. FROM (YYYYMMDD) TO (YYYYMMDD)

b. FROM (YYYYMMDD)

10. APPLICANT WAS EMPLOYED (X one)
a. FULL
TIME

TO (YYYYMMDD)

c. FROM (YYYYMMDD)

TO (YYYYMMDD)

11. ADDRESS (Street, City, State, and Zip Code)

b. PART TIME (Enter number of
periods or hours per week)

12. LENGTH OF SCHOOL YEAR (Specify in months)
13. TYPED OR PRINTED NAME OF EMPLOYER (Last, First, Middle Initial)

14. TITLE

15. EMPLOYER SIGNATURE

16. DATE SIGNED (YYYYMMDD)

NOTE: No salary credit can be awarded for the following:
1. Intermittent Substitute Teaching
2. Student Teaching

DoDEA FORM 5013, 20080630 DRAFT

3. Tutoring
4. Teacher aide or other paraprofessional experience
PREVIOUS EDITION IS OBSOLETE.

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