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Evidence of Completion for Professional Development

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.

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.

Name of Participant (Last, First, Middle Initial)


Title of Professional Development


Date(s) of Activity


LOCATION (Name of Facility, City and State)


Name of Approved Provider


Region, Country, District, Type Code


Name of Provider (If authorized by the approved Provider)


Name of Presenter


Number of Professional Development Hours


Signature of Approved Provider’s Representative



Signature of Participant