Jefferson County Educational Service Center

Certificate of Professional Development Credit

Name SSN# or State ID#

Home Address

Professional Development Activity

Instructor/Facilitator

Date(s)

Clock Hours Equivalent CEUs

Focus of Activity: (Check one)

Context Process Content

(To be completed by the individual/organization conducting the activity)

Program Overview (Attach agenda when applicable):

Program Objectives and Intended Audience:

Opportunities for Participant Follow-up:

Please keep this certificate. The Jefferson County ESC will not be responsible for maintaining participant records.

Verification of Satisfactory Completion

Signature Project Director Date

(Embossed Seal)

Please complete the participant reflection on the back.