-
______________________________________
_______________________________
____________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________________
__________
_______________________________________________________________
__________
_______________________________________________________________
__________________________________________
P
A
R
T
I
2
0
0
6
2
0
0
7
State I
nstructional Materials
?
Committee Member Nomination Form
?
This portion of the nomination form is to be completed by the nominating individual, agency, or association.
Please provide the following information regarding the nominee.
PART II is to be completed by the nominee. Both
PARTS I and II are to be submitted to Patty Ceci, Offi
ce of Instructional Materials, Florida Department of Education,
325 West Gaines, Suite 444, Tallahassee, FL 32399-0400. FAX: (850) 245-0803, E-mail: patty.ceci@fl
doe.org
P
L
E
A
S
E
P
R
I
N
T
1.
Name of nominee:
_______________________________________________________________
_______________________________________________________________
______________________________________
_______________________________________________________________
______________________________________
2.
School district of nominee:
_______________________________________________________________
_______________________________________________________________
_______________________________
_______________________________________________________________
_______________________________
3.
In what capacity do you know the nominee?
_______________________________________________________________
_______________________________________________________________
____________
_______________________________________________________________
____________
Expertise is needed in the subject areas detailed below.
Although not required, preference will be given to
nominees with an Exceptional Student Education (ESE) background and/or expertise in technology.
4.
State Instructional Materials Committee for which nomination is being submitted:
o
Computer Education/Business T
ech Education 6-12
o
Health Education K-5
o
Family & Consumer Science Education 6-12 (including ESE)
o
Health Education/Physical Ed. 6-12 (including ESE)
o
Foreign Language Education K-5
o
Industrial Education 9-12
o
Foreign Language Education 6-8
o
Technology Education 6-12
o
Foreign Language Education 9-12
o
Visual Arts Education K-12
o
Health Sciences Education 6-12
5.
Please check the category for which this nomination is being submitted:
o
Teacher
o
Lay Citizen
o
Supervisor/Curriculum Supervisor
o
School Board Member
6.
Name of agency, association, institution, or
ganization or individual making the nomination:
INDIVIDUAL
TITLE
ASSOCIATION/INSTITUTION/ORGANIZATION
7.
Address of agency, association, institution, or
ganization or individual making the nomination:
CITY
STATE
ZIP
TELEPHONE NUMBER
8.
E-mail: __________________________________________________
I hereby certify that all statements made in this questionnaire are to the best of my knowledge true and correct.
______________________________________________________________________________
__________________________________
NOMINATOR
’S SIGNATURE
DATE
-
P
_______________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_____________________________________________
___________________________________________
_______________________________________________
_______________________________________________________
_______________________________________________________
_____________________________________________
_______________________________________________________
_________________________________________
_______________________________________________________
__________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
P
A
R
T
I
I
2
0
0
6
2
0
0
7
State I
nstructional Materials
?
Committee Member Nomination Form
?
This portion of the nomination form is to be completed by the nominee.
Please return completed form by December 16, 2005, to: Patty Ceci,
Offi
ce of Instructional Materials, Florida
Department of Education, 325 West Gaines, Suite 444, Tallahassee, FL 32399-0400 or FAX: (850) 245-0803.
P
L
E
A
S
E
P
R
I
N
T
1.
Full Name: ____________________________________________________________Pr
eferred Name
________________________________
2.
Address:
_______________________________________________________________
_______________________________________________________________
_______________________________________________
_______________________________________________________________
_______________________________________________
CITY
COUNTY
STATE
ZIP
3. Telephone:
_______________________________________________________________
_______________________________________________________________
_____________________________________________
_______________________________________________________________
_____________________________________________
HOME
BUSINESS
4. E-Mail Address:_____________________________________
Alternate E-mail Addr
ess:
_________________________________________
5. Are you a r
esident of the State of Florida?
o
Yes
o
No
6. School District: ____________________________________School Name (If applicable):
________________________________________
7. Category for which this nomination is being submitted:
o
Teacher
o
Lay Citizen
o
Supervisor/Curriculum Supervisor
o
School Board Member
8. State Instructional Materials Committee for which nomination is being submitted:
o
Computer Education/Business T
ech Education 6-12
o
Health Education K-5
o
Family & Consumer Science Education 6-12 (including ESE)
o
Health Education/Physical Ed. 6-12 (including ESE)
o
Foreign Language Education K-5
o
Industrial Education 9-12
o
Foreign Language Education 6-8
o
Technology Education 6-12
o
Foreign Language Education 9-12
o
Visual Arts Education K-12
o
Health Sciences Education 6-12
9. Occupation:
10. Job Title:
11. Name and address of pr
esent employer:
_______________________________________________________________
_______________________________________________________________
12. Educational background:
_______________________________________________________________
_______________________________________________________________
13. Experience (where applicable):
(a.) T
eaching:
(b.) Administrative:
(c.) Employment:
_______________________________________________________________
___________________________________________
_______________________________________________________________
___________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________
_______________________________________________________________
_______________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________________
_____________________________________________
_______________________________________________________________
_____________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________________
_________________________________________
_______________________________________________________________
_________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________________
__________________________________________
_______________________________________________________________
__________________________________________
_______________________________________________________________
The information requested
below is needed to satisfy Equal
Employment Opportunity reporting
and research requirements.
Social Security Number
___/___/___/
- ___/___ -
___/___/___/___
o
Female
o
Male
Check the race/ethnic gr
oup
with which you identify:
o
White
o
African
American
o
Hispanic
o
Asian or Pacif
c Islander
o
American Indian or Alaskan
Native
___________________________________________
_______________________________________________
_______________________________________________________
_______________________________________________________
_____________________________________________
_______________________________________________________
_________________________________________
_______________________________________________________
__________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________________
______________________________________________________
_______________________________________________________________
______________________________________________________
_______________________________________________________________
_
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________
Subject?
Subject?
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
_______________________________________________________
_______________________________________________________________
14.
?
Public service: (List any public off
ce you now hold or have held and/or any employment by a gover
nment agency or
service on federal, state and/or local advisory committees, commissions, councils or task for
ces.)
15.
?
Affliations: (List national, state, community and/or educational or
ganizations in which you ar
e now or have been a
member.)
16.
?
If you ar
e presently a classr
oom teacher or teaching/curriculum supervisor
, please list below the subjects you ar
e teaching/
supervising and the grade level(s) at which the instruction/supervision is pr
ovided:
17.
?
Do you now hold or have you ever held a teaching certif
cate in the State of Florida or any other state?
o
Yes
o
No
Currently valid?
o
Yes
o
No
Subject Ar
ea(s) and Grade Level(s):
_____________________________________________
Has your certif
cate ever been suspended or r
evoked in this or any other state?
o
Yes
o
No
?
If yes, when?
___________________________________
___________________________________
Where?
____________________________________________________________
?
18.
?
Have you been designated “Teacher of the Y
ear” at any level?
o
Yes
o
No
If yes, please pr
ovide the following infor
mation: Award Level (School, District, Regional, State or National) and A
ward Year.
19.
?
Do you hold National Boar
d Certif
cation?
o
Yes
o
No
If yes, please pr
ovide year certif
ed and certif
cation ar
ea:
_____________________________________________________________
21.
?
Have you ever been convicted of a felony or f
rst degr
ee misdemeanor?
o
Yes
o
No
If yes, what charge(s)?
_______________________________________________________________
_______________________________________________________________
_______________________________
_______________________________________________________________
_______________________________
When?
__________________________________________________
__________________________________________________
Where?
___________________________________________________
22.
?
Have you previously served on a state instructional materials committee?
o
Yes
o
No
When?
__________________________________________________
__________________________________________________
__________________________________________________
Subject?
__________________________________________________
Subject?
__________________________________________________
Have you previously served on a district instructional materials committee?
o
Yes
o
No
When?
__________________________________________________
__________________________________________________
__________________________________________________
Subject?
__________________________________________________
Subject?
__________________________________________________
23.
?
Briefl
y state why you ar
e inter
ested in serving on this committee:
________________________________________________________
I hereby certify that all statements made in this questionnaire are to the best of my knowledge true and correct.
______________________________________________________________________________
__________________________________
NOMINEE’S SIGNATURE
?
DATE
______________________________________________________________________________
__________________________________
SUPERVISOR’S SIGNATURE
?
DATE