M.S.A.D.
49 Teacher Certification
Mentor
Request
Name:________________________
SS #:_____________________
Date
of Certificate’s
Building:_______________________
Expiration:________________
Grade
Level/Subject:______________ Date
Received:______________
Please attach a copy of your current
teaching certificate to this form.
You choose one Mentor:
(Refer to Teacher Action Plan Guide.)
_________________________________________________________
_________________________________________________________
_________________________________________________________
Please send this form to one of the following SSSC Members:
Lynn Hamlin, Benton Elementary School
Linda Vitale, Albion Elementary School
Deborah
Skehan, Clinton Elementary School
Jane Hamilton, Lawrence High School
Sharon Rau, Lawrence Junior High School
Request:
_____________ Approved*
___________
Denied
Signature, SSSC
Chair:_______________________________________
Comments:
_____________________________________________________
_____________________________________________________
This form is due to SSSC by September
21st.
*If approved, work on TAP should begin so
that initial approval for TAP will be no later than October 21st.
Revised
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