Professional Development Request For National Board Certified Teacher Candidates - Arkansas Department Of Education
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1ARKANSAS DEPARTMENT OF EDUCATION
Professional Development Request Form
For National Board Professional Teaching Standards Candidates
Achieving a total score of 225 across all ten entries submitted National Board for Professional Teaching Standards
(NBPTS) candidacy but NOT achieving National Board Teaching Certification may satisfy one-half of the professional
development requirements (30 hours) for the professional development year the candidate receives the score of 225.
Complete and mail or fax the following form to the Office of Professional Licensure. This form is NOT for National
.
Board Certified Teacher. ALL FIELDS ARE REQUIRED
Name: _____________________________________________________________________SSN:_________________
First
Middle
Last
Maiden
Address: ________________________________________________________________________________________
City, State, Zip: ___________________________________________________________________________________
Date NBPTS Scores Received: ______________________________________NBPTS Scores: __________________
Month
Date
Year
Year of Arkansas Teaching License Renewal: _____________________ NBPTS Candidate ID__________________
Current School District or Organization: ______________________________________________________________
(School district, educational service cooperative, public charter school, etc.)
*A photocopy of the NBPTS score sheet must be attached to this form. Candidates can
contact NBPTS for information on score sheets.
NBCT ASSURANCES: Please initial, sign, and date where indicated.
____________ YES, I verify that I received a score of 225 or higher toward NBPTS certification. I am aware that by
taking credit for 30 p.d. hours now, I will only be eligible for 30 p.d. hours credit upon achieving National
Initial
Board Teaching Certification.
____________ 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
____________________________________________________________
________________
NBPTS Candidate 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 Score Sheet 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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