TE-4989 Rev. 6/10 Michigan Department of Education
OFFICE OF PROFESSIONAL PREPARATION SERVICES
P.O. Box 30008, Lansing, MI 48909
ATTN: Krista Ried
Fax: 517-373-0542
NATIONAL BOARD CERTIFICATION
SUBSIDY GRANT APPLICATION
This National Board Certification Application Subsidy grant is a federally and state funded initiative established to provide financial assistance to teachers who volunteer to pursue certification by the National Board for Professional Teaching Standards.
Before completing this form, please read the eligibility requirements in the shaded box on page 2. This completed form must be received at the state address above NO LATER THAN 5:00 P.M. on December 1 of the year of application.
SECTION I: (To be completed by applicant. Type or print with a ballpoint pen.)
Name (First/Middle/Last) ¨ Mr. ¨ Mrs. ¨ Ms. ¨ Dr./ Social Security Number
Home Address
/City
/Zip Code
/Home Phone Number (include area code)
Name of School /District
School Address
/City
/Zip Code
Superintendent’s Name
/Principal’s Name
School Phone Number
/ Fax Number (if available) / Applicants E-mail Address: (*Notifications will be sent via email*)You must complete an application to the National Board for Professional Teaching Standards prior to completing the application for a subsidy grant award. Please provide your candidate ID number: ______Year/Cycle:______
WHAT IS YOUR AREA OF INTEREST FOR NATIONAL BOARD CERTIFICATION? (Check only one from the list below.)
£ Early Childhood Generalist* (ages 3-8) ¨ Early Adolescence through Young Adulthood/English as a New
Language (ages 11-18+)
£ Middle Childhood/Generalist* (ages 7-12)
¨ Early Adolescence through Young Adulthood/Music (ages 11-18+)
£ Early Adolescence/English Language Arts (ages 11-15)
¨ Early Adolescence through Young Adulthood/Physical
£ Early Adolescence/Mathematics (ages 11-15) Education (ages 11-18+)
¨ Early Adolescence/Science (ages 11-15) ¨ Early Adolescence through Young Adulthood/World Languages
Other Than English (ages 11-18+)
¨ Early Adolescence/Social Studies-History (ages 11-15)
¨ Adolescence through Young Adulthood/English Language Arts
£ Early and Middle Childhood/Art (ages 3-12) (ages 14-18+)
£ Early and Middle Childhood/English as a New Language (ages 3-12) ¨ Adolescence through Young Adulthood/Mathematics
(ages 14-18+)
¨ Early and Middle Childhood/Literacy: Reading-Language Arts
(ages 3-12) ¨ Adolescence through Young Adulthood/Science (ages 14-18+)
£ Early and Middle Childhood/Physical Education (ages 3-12) ¨ Adolescence through Young Adulthood/Social Studies-History
(ages 14-18+)
¨ Middle Childhood through Early Adolescence/Mathematics
(ages 7-15) ¨ Early Childhood through Middle Childhood/Music (ages 3-11)
£ Early Adolescence through Young Adulthood/Career and ¨ Early Childhood through Young Adulthood/Library Media
Technical Education (ages 11-18+) (ages 3-18)
£ Early Adolescence through Young Adulthood/Exceptional ¨ Early Childhood through Young Adulthood/School Counseling
Needs (ages Infant-21+) (ages 3-18)
¨ Early Adolescence through Young Adulthood/Art (ages 11-18+) ¨ Retake: _____ # of retakes attempting (funding may not be
available for retakes)
¨ RENEWAL
TE-4989
(Page 2)
-- ALL APPLICANTS MUST SIGN THIS FORM --
DECLARATION OF INTENT: I understand that if I receive an award through this application process and do not complete the assessment process of the National Board for Professional Teaching Standards, or do not teach in a Michigan K-12 school for at least 3 additional years, I must repay the State of Michigan any state-funded portion of the application fee ($1,250).
SIGNATURE:______DATE:______
SECTION II: ATTACH A SHEET OF PAPER ADDRESSING THE FOLLOWING QUESTION:
Ø Why is National Board Certification important to you?
SECTION III: ATTACH A LETTER OF SUPPORT FOR THIS GRANT AWARD FROM ANY ONE OF THE FOLLOWING:
Ø Superintendent or chief school official
Ø President of the school board or governing body
Ø Building principal or equivalent instructional leader
Ø Parent/guardian who is involved in your classroom or school
SECTION IV: ARE YOU RECEIVING SUPPORT FROM ANY OF THE FOLLOWING (INCLUDE THE AMOUNT OF THE AWARD):
Ø District $______
Ø RESA $______
Ø MEA $______
Ø State Farm $______
Ø Other $______
NATIONAL BOARD CERTIRFICATION IN AN IDENTIFIED FIELD WILL ALLOW A TEACHER TO BE DETERMINED TO HAVE MET THE REQUIREMENTS FOR A HIGHLY QUALIFIED TEACHER AS DEFINED WITHIN THE NO CHILD LEFT BEHIND ACT OF 2001.
-- READ THIS FIRST --
ELIGIBILITY: The following criteria must be met in order for your application to be considered by the application review committee. The applicant verifies and commits to the following by placing an “X” in the blank space provided in front of the criterion.
1. ___Possession of a baccalaureate or higher degree.
2. ___Completion of at least three years of teaching experience.
3. ___Commitment to teach at least half time, during the school year of the NBPTS cycle, in a school recognized and approved by the state.
4. ___Has possession of a valid state teacher’s license or teaches in a school recognized and approved by the state.
5. ___Commitment to mentor future candidates for National Board Certification.
6. ___Commitment to teach at least three years in a Michigan K-12 school.