DHETP-4

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2005-2006 MENTORING BONUS PAYMENT FORM

School District/Development Research School:

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DHETP Contact Name:

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DHETP Contact Phone Number:

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DHETP Contact Email:

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Total Number of Salary Bonuses Requested:_________

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NBCT Last Name

NBCT First Name

SS No.

NBPTS ID No.

Address

City

Zip Code

I do hereby request funds for payment of a

bonus for mentoring and related services

to

each

of the above identified educators pursuant to Section 1012.72,

F.S. Related services include instruction in helping educators work more effectively with the families of their students. I certify by my signature that

each

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educator above has met the following requirements:

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1.

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Holds a valid NBPTS certificate or notice of certificate award;

2.

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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.

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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.

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5.

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Has demonstrated satisfactory performance on the most recent, regular annual performance appraisal conducted pursuant to Section 1012.34, F.S.;

6.

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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, F.S., and that the 12 equivalent workdays were not completed during student contact hours during the 196 days of required service;

7.

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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.