2006-2007
Application for $2,500 Annual Award
National Board
Certification
FAXES NOT ACCEPTED
‑ PLEASE TYPE OR PRINT
Applicant
teacher’s name
Teacher's
Social
Security number (required to issue state check)
Name
of school district where teacher is employed
Name
of school building where teacher teaches
Address
of school building
Work
phone # Principal’s name
Teacher’s home address
Home phone #
E‑mail address
Yes No I receive salary compensation from
the school district for providing classroom instruction to students
in the school district. (In order to
be eligible, you must receive at least some portion of your
salary for providing classroom instruction.)
Yes No I have a full-time teaching contract. If no,
please indicate percent of time your contract is for
% (If you possess
less
than a full-time teaching contract, your annual award will
be prorated to reflect the type of contract; i.e., half-time, quarter-time,
etc.)
Yes No I am eligible to receive the final registration fee reimbursement of
$1,150.
Yes No I received a scholarship; therefore,
I am eligible to receive the final registration reimbursement in the amount of $
I have NBC in the
following area
I received
certification in 20_____. I have ______
year(s) remaining of certification.
__________I have
enclosed verification of certification. I understand that I will not receive
the award until I submit verification to the Iowa Department of Education. (You do not need to send the verification of
certification if you have already provided the DE with a copy.)
Candidate’s signature: I understand that my signature gives the DE permission to verify periodically with the National Board for Professional Teaching Standards (NBPTS) my NBC status. I understand that my signature below supersedes my request for confidentiality indicated on my application to the NBPTS.
________________________________________ _______________________________________
Candidate’s
signature Date
________________________________________ _______________________________________
Principal or
superintendent’s signature Date
(Required to verify teacher is employed by an
Hard copy delivered or mailed to: Jody
Crane
Iowa
Department of Education
Second
Floor
Grimes State
Office Building