Appendix J

Rev. 4/18/07

Form for Educators Leaving the LPDC

This verifies that the attached Individual Professional Development Plan was approved

on for

(Date) (Name of Educator)

(Date) (Name of Subcommittee Facilitator)

(Authorized Signatory)

Name of Educator’s School District:

LPDC Name: Jefferson County Educational Service Center Consortium LPDC

LPDC Address: 2023 Sunset Boulevard

Steubenville, Ohio 43952

LPDC Phone Number: (740) 283-3347

LPDC Contact Person: George Allan

(pat)my documents/lpdc 2007/appendix J

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