Winston-Salem/Forsyth County Schools



Winston-Salem/Forsyth County Schools

Exceptional Children Licensed Teacher

PRAXIS Reimbursement Application for HQ Content

Name:

(Last) (First) (Middle)

Social Security Number:

School Assignment:

Subject Currently Teaching:

I currently hold a valid SPI or SPII license in EC area______________________ .

(License Subject Area)

I am submitting original PRAXIS receipts for testing that is required to fulfill the conditions of my HQ EC Content License. I understand that by signing below and submitting this documentation, I am agreeing to continue to teach in my EC license area for Winston-Salem/Forsyth County Schools for TWO years until the end of the 2014-2015 school year or repay all the tuition reimbursement given.

Signature Date

NOTE: State auditing regulations require that you submit original receipts detailing billing charges by category and indicating that you have made payment. Internet receipts must include your name and the amount of your payment, and an itemized list of charges.

Please return this form to Vicki Lee in Human Resources no later than 4:30 PM on

Thursday, December 20, 2012.

Winston-Salem/Forsyth County Schools

HQ EC Licensed Employees 2012-2013 PRAXIS Reimbursement Scholarship Application

(for testing between June 2012 and December 2012)

PLEASE TYPE OR PRINT Please make additional copies as needed.

Name:

Last First Middle/Maiden

School/Location: Social Security #:

Current Assigned Role:

Current Academic Degree and Field:

ο BA or BS in ο EdS (Cert. Adv. Study) in

ο EdD or PhD in ο MA, MS, MLS, Med in

Teaching Area(s) on Your Certificate:

Teaching Area Grade Levels Class (M or A,)

Teaching Experience:

Years (from-to) School/Department (include city/state) Assigned Role

Your Reason(s) for taking EC HQ Content PRAXIS – please check all that apply:

ο to meet requirements for HQ Content (Math, Science, English/LA, Social Studies)

ο to earn additional certification in subject content (certification area)

ο other (state reason)

Page 2

I am applying for a PRAXIS Reimbursement Scholarship for these area(s):

PRAXIS - Subject Scores (attached) Registration Cost Testing Cost

$

$

$

$

**ONE attempt only will be reimbursed per subject area per employee

**ORIGINAL RECEIPTS OR CANCELLED CHECKS MUST BE ATTACHED along with test results.*Receipts must have your name and amount PAID – NOT AMOUNT DUE!! Testing website with emblem will be considered original if paying online.

How will the HQ Content PRAXIS address your professional career goals and our school system goals?

Comments/Recommendation of Your Supervisor:

Signature Date

Scholarship Applicant

Signature Date

Supervisor

Application Deadline: 4:30 PM on Thursday, December 20, 2012

Note: Forms received without ORIGINAL RECEIPTS OR CANCELLED CHECKS will be returned and WILL NOT be eligible for further consideration. Internet receipts must include name and social security number and payment made. Forms must be complete with signature and received before the deadline for consideration. Please submit your completed application to Vicki Lee in Human Resources. Telephone: 336-748-4079.

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