VCTM Award Nomination Form

Please return this by January 15 to:

Jason Cushner

40 Catherine St

Burlington, VT 05401

Or

jcushner@hotmail.com

Applications will be mailed to nominees in February.  Applicants will be asked to submit information about themselves, including two letters of recommendation, one of which you may want to offer to write.  Nominees must return their applications by March 1st.  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 ___________________         School _________________________

Home Address______________________        School Address __________________

City, State, Zip ______________________        City, State, Zip ___________________

Home Phone _______________________         School Phone ____________________

No. of years teaching experience________         *VCTM Zone of Nominee ______

Present grade level ____                

School level: Elementary ____   Secondary ____

Nominator __________________________       Title ____________________________

Nominator Address ___________________       Phone __________________________

___________________________________     Email: __________________________

I will email you once I receive your nomination form.  If you do not get email confirmation within a week 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.