Dual Certification Request Form
WTU Bargaining Unit Members only


INSTRUCTIONS: 
Submit original copies of dual certificates to the Office of Human Resources to the attention of  Mariam  Noah.   
Retain a copy for your records.  You must be a certified permanent classroom teacher in order to be eligible for this incentive.

 Name of employee:                                                                      Position Title:                            Social Security No.:
 
______________________________________________  ____________________     _______-_______-________
 Last                                              First                            Middle     
 
 

School Site_______________________________________ Home/Cell telephone _____-____-____   Email address _______


 
Home address:  _______________________________________________________________________________________
No. and Street                                                                  City/State                                                                                 Zip code


 
 READING______  MATHEMATICS______SPECIAL EDUCATION______PHYSICS_______CHEMISTRY________ESL______


Check the area(s) of dual certification.  
You must have received dual certification in one of the above areas on or after October 1, 2004.

Date of  receipt of Dual Certification: _________

  1. Attach an original copy of your dual certificates.
  2. Attach a copy of your most recent annual performance evaluation or have your supervisor sign below indicating the most recent annual performance evaluation of “Meets Expectations”  or higher.
  3. Dual certification is applicable to those conditions outlined in Article XLI(k2) of the WTU Collective Bargaining Agreement

 

__________________________________________________________                                  ______/_____/_____
Signature of Employee                                                                                                                 Date
          
__________________________________________________________                              ______/_____/______
Signature of Supervisor (indicates teacher has at least a “Meets                                          Date
           Expectations” or higher on the most recent annual performance evaluation)
                  

 Reimbursement Payment:  To be completed by Human Resources
 
____________   Approval of  $1,500
 
____________   Not Approved.  Does not meet the following requirement(s) ___________________________________
 
 
                                 _____________________________________________________________     _____/____/_____
                                  Signature, Highly Qualified Program Administrator                                                       Date


 

__________________________________________________________________________________________________________________