Attachment A

Please complete this online form. This is the first of two forms (the second being Attachment B to be completed at the end of the school year) that will verify your teaching service for this year, a requirement of the Minority Teacher Education Scholarship. You must complete an Attachment A and B form each school year until you fulfill your obligation to the Florida Fund for Minority Teachers, Inc.

Identification Information

Name

First Name

Last Name

Social Security Number

Home/Cell Phone (Primary)

(###)

###

####

Home/Cell Phone (Secondary)

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Graduation Information

Institution Attended

Date of Graduation

If exact day unknown, enter first day of the month.

YYYY

Date Degree Conferred

If exact day unknown, enter first day of the month.

YYYY

Have you passed all sections of the FTCE?

Yes

Teaching Service Information

This form verifies teaching service for the following school year:

Complete Name of School

Name of Principal

School Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

County of Employment

School Phone Number

(###)

###

####

Please Note:

3100’s (i.e. 3110, permanent substitute positions, etc.) are now accepted for repayment. If you have any other temporary teaching position (i.e. pool substitute positions, etc.) this does not satisfy the teaching requirement of the Minority Teachers Education Scholarship, and you should contact our office immediately.

Type of Teaching Position

If you select other, please provide explanation in comments section below.

Present Grade Level and/or Subject

Are you teaching in your field of study?

Yes

Comments

Please provide pertinent information to your position below.