Committee Nomination Form by HC120915052520

VIEWS: 1 PAGES: 3

									                        Ohio Department of Education
                       Lead Content Expert Application


                                    PERSONAL INFORMATION




Name
               First                           Middle Initial                           Last


Position/Occupation:
           Teacher
           Curriculum Specialist/Coordinator
           Higher Education


District/Organization Name                             ____

District/Organization Type:
           Public School                                     ___       Nonpublic School
           Vocational School or Career Center                ___       K-12 Educational Service Agency
           Four-year College or University,                  ___       Other
           Community College, or Technical
           College


School/Building Name                                                     County_____________


Work Address
                                                                City            State          Zip Code

Work Phone                              Work Fax                                Work Email



Home Address
                                                                City            State          Zip Code


Home Phone                                             Home Email



09/14/12                                                 1
                              PROFESSIONAL EXPERIENCE




Degree(s)

Current Licenses/Certificate(s) Held

Current Grade-Level/ Position Assignment                                                   ______

Years of Experience at Current Grade Level/ Position                                       ______

Total Years of Professional Educational Experience                                         ______



Facilitation Experience:




Area(s) of Expertise/Specialization (e.g., Curriculum, ESL, Gifted):




Leadership Roles/Honors (e.g., Department Chair, Teacher of the Year, Committees, NBCT):




Prior Ohio Department of Education Committee Experience:




Subject Area/Interest:
            English Language Arts
            Mathematics
            Science
            Social Studies


Availability:
            June                                            September
            July                              _____ _       October
            August




09/14/12                                                2
Region(s) Availability:
           R1                ______    R5              _   R9      _____   R13
           R2                ______    R6          _____   R10     _____   R14
______     R3                ______    R7          _____   R11     _____   R15
______     R4                ______    R8          _____   R12     _____   R16


View the 16 SST Regions
    Link to http://education.ohio.gov/GD/Templates/Pages/ODE/ODEDetail.aspx?page=587
    Click State Support Team Contact Information



                               RETURN INFORMATION



                          Return Completed Form and Resume to:
                                     Kimberly Mullen
              Ohio Department of Education - Office of Curriculum & Instruction
                            25 South Front Street, Mailstop 509
                                  Columbus, Ohio 43215
                       Phone: (614) 387-2275 Fax: (614) 466-1317
                         E-mail: Kimberly.Mullen@ode.state.oh.us




09/14/12                                       3

								
To top