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:

Zip Code:

Phone :

-

Cell:

-

Personal Email Address:

CPS Email Address:*

*Your CPS email address is required.

DOB:

Gender:

CURRENT TEACHING ASSIGMENT

School Name:

School Address:

Principal's Name:

Unit:

Area:

Mail Run:

Phone:

-

Fax:

-

RACIAL/ETHNIC IDENTIFICATION

Please Select One:

EDUCATION

Highest Degree Earned:

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:

Ages:

How did you hear about National Board Certification?

SESSIONS DATES

Pre-Candidacy Sessions (choose one session):

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

American Indian/Alaskan	Asian	Black (not of Hispanic origin)	Hispanic
Multi-Racial	Pacific Islander	White (not of Hispanic origin)

Bachelors	Master of Fine Arts	Doctorate
Masters	Specialist