Special Education

Application for Individualized Education Program (IEP) Facilitator

The New York State Education Department
P-12: Office of Special Education


Application for Individualized Education Program (IEP) Facilitator - Word word document (76 KB)

Personal History

Name (Last, First, MI) Provide Any Other Names Used     
Street Address                                                                                                                                                                                                 City

State

Zip Code
Home Phone (        )    Work Phone(   )    Cell Phone
(    ) 
EMAIL ADDRESS

Higher Education


College, University or Technical School
Name Of School and Location Attended Credit Hours Completed Major
Subject
Degree
Received
From To
 
 
College,
University
or
Technical
School
           
           
           
Other
Schools
or
Special
Courses
           
           
           
Other
Schools
or
Special
Courses
           
           
           

Professional Licenses/Certifications

Professional Licenses/Certifications Permanent
or

Provisional
Certificate
or
License #
Name of Issuing Agency or State Effective Date Expiration Date
           
           
           

Work Experience (List job experiences, the location and responsibilities that would be an asset to this position)

Name, Address, & Telephone Number of Employer From
(Month/Year)
To
(Month/Year)
Title & Duties
       
       
       
       

Explain why you are interested in being an IEP Facilitator

 

Potential Conflict (Please list any conflict of interest that might interfere with serving as an IEP Facilitator)

 

 

Regions of the State (Please indicate if you would be available to serve as an IEP Facilitator on Long Island, in New York City or both)

 

References (Please list three professional references.)

Name Telephone Number Responsibilities
     
     
     

Affirmation


I affirm that all statements made on this form, including any accompanying papers, are true, accurate and complete to the best of my knowledge under penalty of perjury.  I further authorize investigation of said statements.  Verification of information may be required prior to certification as an IEP Facilitator.  I understand that any false, incomplete or misleading statements made on this form or accompanying papers may nullify NYSED’s consideration of me as a candidate to serve as an IEP Facilitator.
Print Name
Signature Date

 

Last Updated: June 9, 2014