THE STATE EDUCATION DEPARTMENT / THE UNIVERSITY OF THE STATE OF NEW YORK / ALBANY, NY 12234

 

Regents Examination Final Eyes Review Committee Application

Please complete all information.

 

NAME: ________________________________________________________________________________

             (Mr./Mrs./Ms.)                   (First)                                                          (Last)

School District: _____________________________________________________________________

 

School Name: ______________________________________________________________________

 

Street: ____________________________________________________________________________

 

City: ____________________________________________________________________________

 

State:  New York                       Zip: _________________

 

School Telephone: (____)_______________________ Fax (        )_______________________

 

School Email: ______________________________________________________________________

 

Principal: __________________________________________________________________________

 

Home Address: _____________________________________________________________________

 

City:___________________________                 State:_______________ Zip:____________

 

Home Telephone : (____)__________________Home Email: _______________________________

 

Best Way to Reach You (email, phone): ___________     Best Time of Day to Reach You: ________

 

Education: BA/BS:_______________      MA/MS:_________________      Other:_________

 

Certification Area(s): _______________________________________________________________

 

Names of Subject(s) Taught: _________________________         Grade Level ___________________

 

No. of Years Teaching Subject:: ___________                             Current Position: ________________

 

Please check the boxes below that appropriate describe your school.
 

Race/Ethnicity (optional)

q          American Indian or Alaska Native

q          Asian or Pacific Islander

q          Black or African American (not Hispanic origin)

q          Hispanic or Latino

q          White (not Hispanic origin)

q          Multi-Racial (not Hispanic origin)
 
 

 


Text Box: Location □ Long Island □ New York City □ Lower Hudson □ Mid-Hudson □ Capital District □ North Country/Adirondacks □ Central NY □ Western NY □ Southern Tier

 

 

 

 
 
 

 

 

 

 


If you have worked as a consultant for the Office of State Assessment (OSA) in the last three years,

Please: 1) describe the work, and 2) provide the dates you worked for OSA (DATES ARE REQUIRED): ________________________________________________________________________________

________________________________________________________________________________

 

Earliest hour you could be at the State Education Department in Albany: _______________________

If you are selected, how much advance notice do you require: ________________________________

 

Check times available: ____ August 07       _____January 08       _____ June 08        _____ August 08

 

School Administrator’s Acknowledgement: I acknowledge that: ____________________________

                                        (Name of Teacher)

has applied to participate in the review of the New York State Regents Examinations.

 

_________________________________________________________

Signature of School Administrator  (SIGNATURE IS REQUIRED)

 

If you are selected for a review, you will be contacted based on your availability as noted above and our needs. If you are not selected at this time, we will keep your name on file for future reviews.

Thank you for completing this application. 

 

 

***Please fax the application to Attn: Mary Bell at 518-486-5765.