Professional Development Request For National Board Certified Teachers - Arkansas Department Of Education
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1ARKANSAS DEPARTMENT OF EDUCATION
Professional Development Request Form
For National Board Certified Teachers
Achieving National Board for Professional Teaching Standards (NBPTS) certification prior to renewal of the Arkansas
standard teaching license satisfies professional development requirements (60 hours) for the professional development
year the teacher receives NBPTS certification. Complete and mail or fax the following form to the Office of Professional
Licensure. ALL FIELDS ARE REQUIRED
.
Name: _____________________________________________________________________SSN:_________________
First
Middle
Last
Maiden
Address: ________________________________________________________________________________________
City, State, Zip: ___________________________________________________________________________________
Date National Board Teacher Certification Achieved: ____________________NBPTS Candidate ID: _____________
Month
Date
Year
Year of Arkansas Teaching License Expiration: _____________________
Current School District or Organization: ______________________________________________________________
(School district, educational service cooperative, public charter school, etc.)
*A photocopy of the National Board Certification must be attached to this form.
NBCT ASSURANCES: Please initial, sign, and date where indicated.
____________ YES, I achieved National Board Teacher Certification on the above date.
Initial
____________ YES, I understand this is for the purpose of licensure renewal by the ADE only. My school district does
not have to accept these hours towards the professional development required by my school district.
Initial
____________________________________________________________
________________
NBCT Signature
Date
For Office of Professional Licensure Use Only
Reviewed by: ______________________________Date: _______________
Application Approved: _____for _____hours professional development credit for the __________school year.
Application Denied: _____
Reason for Denial:
_____ The professional development request form is incomplete.
_____ The National Board Certificate was not attached.
_____ National Board Certification could not be confirmed.
_____ Other_______________________________________________________________________________________
Mail or Fax to:
Office of Educator Licensure
Arkansas Department of Education
Four Capitol Mall, Room 106B
Little Rock, AR 72201-1071
Fax #501-682-4898
1/23/13
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