Fee Subsidy Information
�
Dale Hickam Excellent Teaching Program
€
National Board for Professional Teaching
Standards (NBPTS)
€
Applicant-2003-2004
€
This form
must
be completed for
each teacher applicant
for the NBPTS certification
$2,070
fee
subsidy. Attach the completed NBPTS application form, teacher’s
$230
payment-
payable to
NBPTS
, and signed Letter of Intent/Promissory Note.
Send the original and one legible copy of
each document to the Dale Hickam Excellent Teaching Program, 325 West Gaines Street,
Room 126, Tallahassee, Florida 32399.
Please type or print legibly
. DO NOT SEND
DIRECTLY TO NBPTS.
Name of School District/Developmental Research School/Charter School
Excellent Teaching Program Contact
Address
School Year
(
)
(
)
Telephone Number
Fax Number
E-mail address
Name of NBPTS Certification Applicant (Last, First, Middle Initial)
Applicant’s Address
City
Zip
(
)
Home Telephone Number
Social Security Number
NBPTS ID Number
(
)
School Name
School Telephone Number
School Address
City
Zip
NBPTS Certificate Area Sought
NBPTS Certificate Area Code Number
NBPTS Specialty Code
Applied Before (Yes/No)
Year(s) Applied
The following applicant documents and one copy of each document are attached:
•
?
Completed NBPTS Certification Application Form-
paper or on-line
(and non-standard administration
form if needed)
•
Applicant’s
$230
check or money order
payable to NBPTS
•
Signed Letter of Intent/Promissory Note
I do hereby certify by my signature that the above identified teacher has demonstrated satisfactory
teaching performance on the most recent regular performance appraisal conducted pursuant to
Section 1012.34, Florida Statutes.
Signature, District School Superintendent or Director, Developmental Research School
Date
(Green
)
Dale Hickam Excellent Teaching Program
€
National Board for Professional Teaching Standards (NBPTS)
€
Letter of Intent-2003-2004
€
This form must be completed and signed by each teacher applicant for the NBPTS Certification
$2,070
subsidy fee. Attach the NBPTS application form, teacher’s
$230
payment--
payable to
NBPTS
, and signed Fee Subsidy Information form.
Send the original and one legible copy of
each document to Dale Hickam Excellent Teaching Program, 325 West Gaines Street, Room
126, Tallahassee, Florida 32399-0400
. Please type or print legibly. DO NOT SEND
DIRECTLY TO NBPTS.
I, the undersigned, have applied to participate in the National Board for Professional Teaching
Standards (NBPTS) process to become certified by the NBPTS. By my signature, I certify that I will
participate in the NBPTS process during the school year for which the fee subsidy is paid and
begin the certification process as directed by the NBPTS. I request that the State of Florida pay
$2,070
of the
$2,300
fee to the NBPTS. I
understand
and
agree
that if I do not complete the
NBPTS on or before
September 1, 2004
, or if I complete the certification program and
do not
teach
in a public school in Florida the year
immediately following
the completion of the program,
I will owe and will remit to the State of Florida the
total
amount of the fee subsidy paid on my
behalf that is not refunded by the NBPTS.
See reverse side for repayment schedule.
Applicant’s Signature
Date
Promissory Note
Therefore, in consideration for the State of Florida payment of the application fee subsidy for my participation
in the NBPTS process, I promise to pay the State of Florida the amount owed and not refunded by the
NBPTS, if I withdraw or do not complete the NBPTS certification process on or before
September 1, 2004
, or
I complete the process but I do not teach in a Florida public school the year
immediately following
completion of the NBPTS certification process.
ise to pay all reasonable attorney’s fees for trials
and all appeals and other costs and charges that are necessary for the collection of any amount not paid
when due
.
_____________________________________________________________________________________
Signature
Date
NOTE: The subsidy fee will not be paid to the NBPTS until this promissory note has been signed and received by
the Florida Department of Education and the other required application information has been completed.
I also prom
You Must Complete the Following Application Information
(Please type or print legibly)
Name of NBPTS Certification Applicant (Last, First, Middle Initial)
Applicant’s Address
City
Zip
(
)
Home Telephone Number
Social Security Number
NBPTS ID Number
(
)
School Telephone Number
School Address
School District
2003
(blue)
Letter of Intent Continued
€
Dale Hickam Excellent Teaching Program for Florida Teachers
€
PLEASE READ CAREFULLY
€
Background:
?
The
Dale Hickam Excellent Teaching Program Act provides Florida teachers
seeking National Board for Professional Teaching Standards (NBPTS) certification
an application subsidy of
$2,070
that is paid to the NBPTS. The law also requires
the applicant to repay the fee subsidy to the State of Florida if all conditions of the
law are not met.
An NBPTS application fee subsidy is a one-time payment and
may not be duplicated for
an individual who has completed the process
.
Eligibility:
?
-The fee subsidy applies only to
public school full-time classroom teachers
who are eligible to participate in the NBPTS certification program.
-A satisfactory teaching performance appraisal pursuant to Section 1012.34,
Florida Statutes, is required.
-All
Dale Hickam Excellent Teaching Program and NBPTS requirements,
procedures, and deadlines adhered to.
-A Declaration of Intent/Promissory Note must be signed and submitted by the
school district/DRS for each applicant.
Repayment of Fee Subsidy to the State of Florida 2003-2004
€
(Make check/money order payable to the Department of Education)
€
Conditions
(Please read carefully)
Amount Due to
State of Florida
Withdrawal AFTER
Portfolio Due Date
Written withdrawal letter must reach
San Antonio
On
or
Before February 16,
2004, and Before Taking Assessment
$70
$2,070
Written withdrawal letter must reach
San Antonio
On
or
Before March 16,
2004, and Before Taking Assessment
$70
$2,070
Written withdrawal letter must reach
San Antonio
On
or
Before April 16,
2004, and Before Taking Assessment
$70
$2,070
Failure to complete the NBPTS
portfolio/assessment process
$2,070
Failure
to teach in a Florida public
school the year
immediately following
successful or unsuccessful completion of
program
$2,070
If one or more of the above conditions exist, you are required by Florida law to make repayment.
Only death of an applicant, permanent and total disability of an applicant, reassignment of an
applicant’s military spouse outside the State of Florida, or extenuating circumstances as
established by the State Board of Education may be considered for forgiveness or deferment of
payment.
WRITTEN notices of withdrawal from the program must be sent to the following:
Dale Hickam Excellent Teaching Program
NBPTS Processing Center
District ETP Contact
Florida Department of Education
19500 Bulverde Road
Local Address
325 West Gaines Street, Room 126
San Antonio, Texas 78259-3701
Tallahassee, Florida 32399-0400
Salary Bonus Request Form
€
Dale Hickam Excellent Teaching Program
€
National Board for Professional Teaching Standards (NBPTS)
€
Certified Teacher-2003-2004
€
This form must be completed for each NBPTS certified teacher for whom the salary bonus payment
is requested.
Send this form to the Dale Hickam Excellent Teaching Program, 325 West
Gaines Street, Room 126, Tallahassee, Florida 32399-0400
.
Please type or print legibly.
School District/Developmental Research School
Excellent Teaching Program Contact
School Year
(
)
(
)
Telephone Number
Fax Number
E-mail address
Name of NBPTS Certified Teacher (Last, First, Middle Initial)
NBPTS Certification Area
Year Certified
NBCT’s Address
City
Zip
(
)
Home Telephone Number
Social Security Number
NBPTS ID Number
(
)
School Telephone Number
School Address
City/Zip
I do hereby request funds for payment of a
salary bonus
to the above-identified teacher pursuant
to Section 1012.72, Florida Statutes. I certify by my signature that the above teacher has met the
following qualifying requirements:
1.
holds a valid certificate issued by the National Board for Professional Teaching Standards;
2.
?
is
currently
employed as a
full-time classroom teacher
in a public school in this district or in
a developmental research school, or charter school; and
3.
?
has demonstrated satisfactory teaching performance on the most recent, regular annual
performance appraisal conducted pursuant to Section 1012.34, Florida Statutes.
Signature, District School Superintendent or Director, Developmental Research School
Date
2003
(Pink)
Mentoring Services Bonus Request Form
€
Dale Hickam Excellent Teaching Program
€
National Board for Professional Teaching Standards (NBPTS)
€
Certified Teacher-2003-2004
€
This form must be completed for each NBPTS certified teacher for whom the mentoring services
bonus is requested.
Send this form to the Dale Hickam Excellent Teaching Program, 325
West Gaines Street, Room 126, Tallahassee, Florida 32399-0400.
Please type or print legibly.
School District/Developmental Research School
Excellent Teaching Program Contact
School Year
(
)
(
)
Telephone Number
Fax Number
E-mail address
Name of NBPTS Certified Teacher (Last, First, Middle Initial)
NBPTS Certification Area
Year Certified
NBCT’s Address
City
Zip
(
)
Home Telephone
Social Security Number
NBPTS ID Number
(
)
School Telephone
School Address
City/Zip
I do hereby request funds for payment of a salary bonus for
mentoring and related services
for the above-
identified teacher pursuant to Section 1012.72, Florida Statutes. I certify by my signature that the above-
identified teacher has met the following qualifying requirements:
1.
holds a valid certificate issued by the National Board for Professional Teaching Standards;
2.
?
is currently employed as a
full-time classroom teacher
in a public school in this district or in a
developmental research school, or charter school;
3.
?
has demonstrated satisfactory teaching performance on the most recent, regular annual performance
appraisal conducted pursuant to Section 1012.34, Florida Statutes; and
4.
?
has provided (as previously agreed to in writing) the equivalent of 12 workdays of mentoring and related
services to public classroom teachers pursuant to Section 1012.72, Florida Statutes. I also certify that the
12 equivalent workdays were not completed
during student contact hours
during the 196 days of
required service.
Signature, District School Superintendent or Director, Developmental Research School
Date
2003
Yellow