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. 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. 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
Allowed
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DOE Memorandums, Reports & Other Documents 
