2005-2006 SALARY BONUS PAYMENT FORM

Total Number of Salary Bonuses Requested:_________

Batch No.:________

NBCT Last Name NBCT First Name SS No. NBPTS ID No.

Address City Zip Code

DHETP-4

School District/Development Research School:

DHETP Contact Name:

DHETP Contact Phone Number:

DHETP Contact Email:

I do hereby request funds

 

for payment of a

salary bonus

to

each

of the above identified educators pursuant to Section 1012.72, F.S. I

certify by my signature that

each

educator above has met the following requirements:

1. Holds a valid NBPTS certificate or notice of certificate award;

2. Is currently employed full-time as instructional personnel within the meaning of Section 1012.01(a)-(c), F.S., as reflected by contract,

the school district's personnel salary schedule, or the district's approved staffing plan;

3. Is currently engaged exclusively in activities that further student instruction; for example, through advising, teaching and mentoring

students and offering information resources to students;

4. Teaches 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, F.S.;

6. Holds a valid Florida educator’s certificate that has not 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

within the five (5) years immediately

prior to the district’s certification

pursuant to Section 1012.72(2)(c), Florida Statutes.