VCTM Award Nomination Form

Please return this by January 7th to:

Jason Cushner

36 Crowley St.

Burlington, VT 05401

Or

jcushner@hotmail.com

Applicants will be asked to submit information about themselves, including one letter of recommendation, which you may want to offer to write.  Nominees must return their applications by February 11^th.  Applicants must have taught students at least half time for three years or more, and must be a classroom teacher in the region from which nominated at the time of the nomination.  Teachers may apply any number of times if not a winner, submitting a new application each time, but an awardee may win only once.

Name of Nominee ___________________         Email______________________________

Address __________________                            *VCTM Zone of Nominee ______

City, State, Zip ______________________        School_____________________________

Home Phone _______________________         No. of years teaching experience ____

Present grade level ____                

School level: Elementary ____   Secondary ____

Nominator __________________________       Title ____________________________

Phone __________________________

Email: __________________________

Why are you choosing to nominate this teacher?

You should receive an email confirming receipt of the nomination.  If you do not get email confirmation within 2 weeks of submitting, please contact me to ensure receipt.

*VCTM Zones

If you do not know your VCTM zone, leave blank and we will fill in for you.