Application for Teacher Certification Fee Subsidy
Dale Hickam Excellent Teaching Program
This form
must
be completed to apply for the NBPTS certification fee subsidy.
Send the original and one legible copy
of this application and all requested documents to the Dale Hickam Excellent Teaching Program, 325 West Gaines Street,
Room 126, Tallahassee, FL 32399.
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 Subject or Grade Level Currently Teaching
School Address City Zip
NBPTS Certificate Area Sought NBPTS Certificate Area Code Number NBPTS Specialty Code
$
Applied Before (Yes/No)
Year(s) Applied Withdrawal Amount(s) Paid
Attach the following applicant documents and one copy of each document:
•
Copy of 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 certify by my signature that the above teacher has met the following qualifying requirements:
1. Is
currently
employed
full-time
as instructional personnel
within the meaning of Section 1012.01(2)(a)-(c), Florida Statutes, as
reflected by contract, the school district’s personnel salary schedule, or the school district’s approved staffing plan;
2. Engaging exclusively in activities that further student instruction; for example, through advising, teaching and mentoring students
and offering information resources to students;
3. Teaching students a majority of the time;
4. Has demonstrated satisfactory performance on the most recent, regular annual performance appraisal conducted pursuant to
Section 1012.34, Florida Statutes;
5. Holds a valid Florida educator’s certificate that has never been subject to discipline as a result of a final order of the Education
Practices Commission after a formal, informal, or show cause hearing or settlement agreement;
6. Is adhering to all school district, Department, and NBPTS requirements, procedures, and deadlines.
Signature, District School Superintendent or Director, Developmental Research School Date
Signature, Teacher
Date
Form No. DHETP-1 Feb. 2004
Letter of Intent/Promissory Note
Dale Hickam Excellent Teaching Program
This form must be completed to apply for the NBPTS certification fee subsidy. Attach a copy of the completed NBPTS
application form, teacher’s
$230
payment
payable to
NBPTS
, and signed Application for Teacher Certification Fee
Subsidy.
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 process on or before
March 31, 2005
, 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
March 31, 2005
, 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. I also promise 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.
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
Form No. DHETP-2 Feb. 2004
Certification Fee Subsidy Instructions
Dale Hickam Excellent Teaching Program
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: Eligibility for the certification fee subsidy depends upon the following:
Applicants must be employed full-time as instructional personnel
within the meaning of 1012.01(2)(a)-(c), Florida
Statutes, as reflected by contract, the school district’s personnel salary schedule, or the school district’s approved
staffing plan;
Engaging exclusively in activities that further student instruction; for example, through advising, teaching and
mentoring students and offering information resources to students;
Teaching students a majority of the time;
Applicants must complete and sign the following forms and submit all items they require: Application for Teacher
Certification Fee Subsidy and Letter of Intent/Promissory Note, available at the Florida Department of Education,
Florida Excellent Teaching Program, 325 W. Gaines St., Ste. 126, Tallahassee, FL 32399;
Applicants must demonstrate satisfactory performance on the most recent, regular annual performance appraisal
conducted pursuant to Section 1012.34, Florida Statues;
Applicants must hold a valid Florida educator’s certificate that has never been subject to discipline as the result of a
final order of the Education Practices Commission after a formal, informal, or show cause hearing or settlement
agreement;
Applicants must adhere to all school district, Department, and NBPTS requirements, procedures, and deadlines.
Repayment: If one or more of the below-referenced circumstances arise 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.
Repayment of Fee Subsidy to the State of Florida 2003-2004
Conditions
(Please read carefully)
Amount Due to
State of Florida
Withdrawal AFTER
Portfolio Due Date
Written withdrawal letter must reach
Ewing, N.J.,
On
or
Before
March 31, 2005,
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
In the event repayment is necessary, make your check or money order payable to the Department of Education and
provide WRITTEN notice of withdrawal from the program to each of the following:
Dale Hickam Excellent Teaching Program NBPTS Processing Center District ETP Contact
Florida Department of Education Post Office Box 6887 Local Address
325 West Gaines Street, Room 126 Ewing, New Jersey 08628-6887 City, State, Zip
Tallahassee, Florida 32399-0400
Form No. DHETP-3 Feb. 2004
Salary Bonus Request Form
Dale Hickam Excellent Teaching Program
This form must be completed for the Dale Hickam Excellent Teaching Program salary bonus.
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 Name School Address School Telephone Number 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 NBPTS certificate or notice of certificate award;
2. Currently employed full-time as instructional personnel within the meaning of Section 1012.01(2)(a)-(c), Florida Statutes, as
reflected by contract, the school district’s personnel salary schedule, or the school district’s approved staffing plan;
3. Currently engaged exclusively in activities that further student instruction; for example, through advising, teaching and mentoring
students and offering information resources to students;
4. Teaching students a majority of the time;
5. Has demonstrated satisfactory performance on the most recent, regular annual performance appraisal conducted pursuant to
Section 1012.34, Florida Statutes;
6. Holds a valid Florida educator’s certificate that has never been subject to discipline as a result of a final order of the Education
Practices Commission after a formal, informal, or show cause hearing or settlement agreement.
Signature, District School Superintendent or Director, Developmental Research School Date
Signature, Teacher
Date
Form No. DHETP-4 Feb. 2004
Mentoring Services Bonus Request Form
Dale Hickam Excellent Teaching Program
This form must be completed for the Dale Hickam Excellent Teaching Program mentoring and related services bonus.
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
Name
School
Address
School
Telephone
Number
City/Zip
I do hereby request funds for payment of a 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.
Meets the requirements for the salary bonus;
2.
Holds a valid NBPTS certificate or notice of certificate award;
3.
Currently employed full-time as instructional personnel within the meaning of Section 1012.01(2)(a)-(c), Florida Statutes, as
reflected by contract, the school district’s personnel salary schedule, or the school district’s approved staffing plan;
4.
Currently engaged exclusively in activities that further student instruction; for example, through advising, teaching and mentoring
students and offering information resources to students;
5.
Teaching students a majority of the time;
6.
Has demonstrated satisfactory performance on the most recent, regular annual performance appraisal conducted pursuant to
Section 1012.34, Florida Statutes.;
7.
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. Related services include instruction in helping teachers work
more effectively with the families of their students. I also certify that the 12 equivalent workdays were not completed during student
contact hours during the 196 days of required service;
8.
Holds a valid Florida educator’s certificate that has never been subject to discipline as a result of a final order of the Education
Practices Commission after a formal, informal, or show cause hearing or settlement agreement.
Signature, District School Superintendent or Director, Developmental Research School
Date
Signature, Teacher
Date
Form No. DHETP-5
Feb. 2004
FLORIDA DEPARTMENT OF EDUCATION
Dale Hickam Excellent Teaching Program
Withdrawal Form
The Florida Department of Education, through the Dale Hickam Excellent Teaching Program Act, Section 1012.72,
Florida Statutes, has provided you with a
$2,070
fee subsidy to apply for National Board for Professional Teaching
Standards (NBPTS) Certification. If, during the course of the National Board process, you find it necessary to withdraw,
you are
required
to submit a written withdrawal request to the Florida Department of Education, as well as to the
National Board for Professional Teaching Standards. If you withdraw
before
your portfolio due date, the National Board
will refund to the Department of Education
$2,000
of the
$2,070
paid on your behalf. The remaining
$70
balance is to be
paid by you. If you withdraw
after
your portfolio due date, or if you take the written assessment and later decide to
withdraw, the National Board will refund
no
portion of the fee subsidy and you will be required to repay the Department
the entire
$2,070
fee
. Please use this form as written notification to the Department of Education of your
withdrawal from the National Board process. Make check payable to the Department of Education and send to
325 West Gaines Street, Room 126, Tallahassee, Florida 32399
.
Applicant’s Last Name
First Name Initial
Applicant’s Address City State Zip
( )
Applicant’s School School Address School Telephone #
Social Security # NBPTS ID # School District
$70.00 $
Amount Due
Amount Paid
Signature Withdrawal Date
Reason(s) for withdrawal:
2004