Date: School:

Name:

Teaching Out-of-Field YES NO

Required by Individual Professional Development Plan YES NO

Request is for

____ Test Cost Reimbursement complete the information below

____ Course Cost Reimbursement complete the information below

TEST(s)	1^st Request	2^nd Request
Test Administered
Date Administered
Administration Site
Test Format
Test Fee
Pass/Fail
Required by DOE for Certification
Total amount	NOTE: Participant must provide original statement from college/university.
$

Course Request(s)	1^st Request	2^nd Request
Course
Dates
Course Site/Online
Course Fee
Other information
Pass/Fail
Required by DOE for Certification
Total amount	NOTE: Participant must provide original statement from college/university.
$