The New York State Education Department
The New York State Education Department
P-12: Office of Special Education
Application for Individualized Education Program (IEP) Facilitator
Personal History
|Name (Last, First, MI) |Provide Any Other Names Used |
|Street Address |City |State |Zip Code |
| | | | |
|(City) (State) (Zip) | | | |
|Home Phone |Work Phone |Cell Phone |
| | | |
|( ) |( ) |( ) |
|EMAIL ADDRESS |
Higher Education
|College, |Name Of School and Location |Attended |Credit Hours |Major |Degree |
|University or | | |Completed |Subject |Received |
|Technical School| | | | | |
| | | | | | |
| | |From |To | | | |
| | | | | | | |
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|College, | | | | | | |
|University | | | | | | |
|or | | | | | | |
|Technical | | | | | | |
|School | | | | | | |
| | | | | | | |
| | | | | | | |
|Other | | | | | | |
|Schools | | | | | | |
|or | | | | | | |
|Special | | | | | | |
|Courses | | | | | | |
| | | | | | | |
| | | | | | | |
|Other | | | | | | |
|Schools | | | | | | |
|or | | | | | | |
|Special | | | | | | |
|Courses | | | | | | |
| | | | | | | |
| | | | | | | |
Professional Licenses/Certifications
|Professional Licenses/Certifications |Permanent |Certificate |Name of Issuing Agency or |Effective Date|Expiration Date |
| |or |or |State | | |
| |Provisional |License # | | | |
| | | | | | |
| | | | | | |
| | | | | | |
Work Experience (List job experiences, the location and responsibilities that would be an asset to this position)
|Name, Address, & Telephone Number of Employer |From |To |Title & Duties |
| |(Month/Year) |(Month/Year) | |
| | | | |
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Explain why you are interested in being an IEP Facilitator
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Potential Conflict (Please list any conflict of interest that might interfere with serving as an IEP Facilitator)
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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)
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References (Please list three professional references.)
|Name |Telephone Number |Responsibilities |
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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 |
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