THE STATE EDUCATION DEPARTMENT / THE UNIVERSITY OF THE STATE OF NEW YORK / ALBANY, NY 12234

Regents Examination Teacher Review Committee Application

Updated Version, Effective February 12, 2004

Only this version of the application will be accepted.

Applications are accepted continuously. Please complete all information.

NAME: _________________________________________________________________________

††††††††††† (Ms./Mr./Mrs.)†††††††††††††††††††††††††† (First)††††††††††††††††††††††††††††††††††††††† (Last)

Home Address: ________________________________________________________________

††††††††††††††††††††††† (Street)†††††††††††††††††††††††††††††††††††††††††††††††† (City)††† ††††††† (State)††††† (Zip Code)

Home Telephone:(___) ______________________ Home Email ____________________

Best Way to Reach You (email, phone) ___________________________________________

Best Time of Day to Reach You __________________________________________________

School Name: _____________________________________________________________

Street: ___________________________________________________________________

City: ____________________________________†††††††††††††††††††††††† State: New York††††††††††† ††

Zip: _________________ County:_____________________

School Telephone: (____)_______________________ Fax (____)______________________

School Email: _____________________________________________________________

Principal: _________________________________________________________________

School District: ____________________________________________________________

Certification Area: _____________________________________________________________

Course(s)Taught: _____________________________________________________________

Grade Level(s) ________________________________________________________________

No. of Years Teaching Subject: ___________________________________________________

Have you ever worked as a consultant for the Office of State Assessment?†† ___ Yes†† ___ No

If yes, 1) describe the work, and 2) provide the dates of employment: _____________________________________________________________________________

_____________________________________________________________________________

Earliest hour you could arrive at the State Education Department in Albany: _________________

If you are selected, how much advance notice do you require: __________________________

Check times available: ____ June 04 ___ August 04††

If you are currently teaching, please ask your schoolís principal/administrator to acknowledge your application

By completing and signing the statement below:

School Administratorís Acknowledgement: I acknowledge that

____________________________________________________________________

†††††††††††††††††††††††††††††††††††††††††† Name of Teacher

has applied to participate in the review of the New York State Regents Examinations.

  __________________________________________________________________

†††††††††††††††††††††††††††††† Signature of School Administrator

Review Committee participants are selected to provide representation from across the State. If you are selected for a review, you will be contacted based on your availability as noted above. If you are not selected at this time, we will keep your name on file for future reviews.

Thank you for completing this application.

The deadline for applying for a Teacher Review Committee for the June 2004 Regents Examinations is March 15, 2004.

Completed forms should be faxed to Judi Golombiski at 518-473-7737. †††††††††††††††††††††††††††††††††††††††††††††††††††††††