School Mentor Information And Stipend Request Form/form W-9 - Request For Taxpayer Identification Number And Certification Page 2
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3School Mentor Information and Stipend Request
(School mentor = cooperating teacher or internship mentor)
School Mentor:
Semester: Fall _____ Spring _____Summer____
Year: ____________
E-Mail:
School:
Mentor’s Mailing Address:
Student Teacher or Intern’s Name:
Please initial below confirming you have completed the following mentor requirements:
I have viewed the mentor training video provided by the LU School of
Education at:
I have/will complete the demographic information and the other required
assessments in the FEM (Field Experience Management) on Live Text.
If I am outside of the state of Virginia, I have attached a copy of my current
license or certification with this stipend form.
I am also an employee of Liberty University during this current reporting year.
Yes
No
Each mentor receives a stipend of $200 for a 15 week student teacher/internship placement or a $100
stipend for a 7 ½ week student teacher/internship placement. Please indicate if you are mentoring this
candidate for a 15 week or 7 ½ week placement.
Stipend: $200.00 for 15 week placement
$100.00 for 7 ½ week placement
The stipend is paid at the end of the semester upon receipt of all paperwork (this signed contract and the
W9 or W8BEN form). Your SSN is required on the W9 and your signature must be on both documents in
order for the stipend to be released from Accounts Payable. At the end of the semester, the stipend
check will be mailed to the address that is noted on the W9 or W8BEN form.
The following information is requested for compliance with licensure standards and is used for data
recording only:
Gender:
Ethnicity:
US Citizen: (if No, then the W8BEN form must be
submitted in lieu of the W9.
Endorsement area(s) (must match student teacher or
Grades/Subjects currently employed:
intern):
Degree(s):
Institution for each degree:
Years of teaching and/or school personnel
Number of student teachers or interns previously
experience (3 years minimum):
mentored:
Other professional experience (professional memberships, conferences attended, presentations,
publications):
Required signature of School Mentor: ___________________________________________________
Please mail the required forms to:
Teacher Licensure Office, Liberty University
Box 710098, 1971 University Blvd., Lynchburg, VA 24515
Revised April 2015
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