NATIONAL BOARD PRE-CANDIDATE REGISTRATION FORM
Please complete all fields on the application. Look up the certificate areas at the National Board for Professional Teaching Standards website at
http://www.nbpts.org/for_candidates/certificate_areas1
to ensure that you are choosing the correct certificate. You must be teaching students in that content field and age range next year.
Finally, check the 2-day pre-candidate session you will be attending.
CONTACT INFORMATION
First Name:
Last Name:
Social Security Number (last 4 digits only):
Current Address:
Apt.:
City:
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Phone :
-
-
Cell:
-
-
Personal Email Address:
CPS Email Address:
*
*Your CPS email address is required.
DOB:
Gender:
Male
Female
CURRENT TEACHING ASSIGMENT
School Name:
School Address:
Principal's Name:
Unit:
Area:
Mail Run:
Phone:
-
-
Fax:
-
-
RACIAL/ETHNIC IDENTIFICATION
Please Select One:
American Indian/Alaskan
Asian
Black (not of Hispanic origin)
Hispanic
Multi-Racial
Pacific Islander
White (not of Hispanic origin)
EDUCATION
Highest Degree Earned:
Bachelors
Master of Fine Arts
Doctorate
Masters
Specialist
Institution Conferring Degree:
Years Conferred:
ILLINOIS CERTIFICATES AND ENDORSEMENTS
Certificate Type:
Certificate Number:
Endorsements:
Expiration Date:
CURRENT TEACHING LEVEL
Note: You must have at least 3 total years of experience.
Years of teaching experience:
Current teaching level and ages of students:
Current teaching grade and level:
National Board Certificate Name:
Early Childhood Generalist
Middle Childhood Generalist
Early Childhood-Young Adulthood – Specialist
Early Childhood-Young Adulthood – Counseling
Early and Middle Childhood – Art
Early and Middle Childhood – Literacy
Early and Middle Childhood – English
Early and Middle Childhood – Physical Education
Early and Middle Childhood – Music
Early Adolescence – English Language Arts
Early Adolescence – Mathematics
Early Adolescence – Science
Early Adolescence – Social Studies/History
Early Adolescence-Young Adulthood – Art
Early Adolescence-Young Adulthood – Career
Early Adolescence-Young Adulthood – English
Early Adolescence-Young Adulthood – Physical Education
Early Adolescence-Young Adulthood – World Languages
Early Childhood-Young Adulthood – Library/Media
Early Adolescence-Young Adulthood – Music
Adolescence-Young Adulthood – English
Adolescence-Young Adulthood – Mathematics
Adolescence-Young Adulthood – Science
Adolescence-Young Adulthood – Social Studies/History
Ages:
Birth-21+
3-8
3-12
3-18+
7-12
11-15
11-18+
14-18+
How did you hear about National Board Certification?
SESSIONS DATES
Pre-Candidacy Sessions (choose one session):
January 16th & 17th, 2008
February 4th & 6th, 2008
March 10th & 11th, 2008
April 23rd & 24th, 2008
May 7th & 8th, 2008
May 21st & 22nd, 2008
June 4th & 5th, 2008
June 10th & 11th, 2008
All sessions will be held at the National Board Resource Center at Talcott Academy, 1840 W. Ohio. All sessions are from 4:30 p.m. - 7:30 p.m.
PRINT A COPY OF THIS FORM BEFORE CLICKING THE SUBMIT BUTTON