ࡱ> QSP v6bjbj JD"""""E0$u'"@Q" iii iii8ࡩK x#F(t0E0g"ig"88g"L(iiEg" : APPLICATION FOR NATIONAL BOARD CERTIFICATION SOUTHWEST MISSISSIPPI WORLD-CLASS TEACHING INITIATIVE (SMWCTI) Please complete the following information and return to the address indicated below. Name: Home Address: Street City State Zip Code School Name School District: Telephone Number(s)_ E-mail Address Check Area of Specialist(s) %Early Adolescence/Generalist Ages 11-15 %Early Childhood/Generalist Ages 3-8 %Middle Childhood/Generalist Ages 7-12 %Early and Middle Childhood/Art Ages 3-12 %Early Adolescence through Young Adulthood/Art Ages 11-18+ %Early Adolescence through Young Adulthood/Career and Technical Education Ages 11-18+ %Early Adolescence/English Language Arts Ages 11-15 %Adolescence and Young Adulthood/English Language Arts Ages 14-18+ %Early and Middle Childhood/English as a New Language Ages 3-12 %Early Adolescence Through Young Adulthood/Health Education Ages 11-18+ %Early and Middle Childhood/Literacy: Reading-Language Arts Ages 3-12 %Early Adolescence through Young Adulthood/English as a New Language Ages 11-18+ %Early Childhood through Young Adulthood/Exceptional Needs Specialist Ages Birth-21+ %Early Childhood through Young Adulthood/Library Media Ages-3-18+ %Early Adolescence/Mathematics Ages 11-15 %Adolescence and Young Adulthood/Mathematics Ages 14-18+ %Early    !"#%&'()+-Єq^нKн$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ h75CJOJPJQJ\aJjhOyhOyUm   4 F G H d j  0E^0d8 #mgd7 0^0 DP^P 0^0 'u 8 ^8 $0]^0d~dhN]^`-.123456789:;=>?@ABCDGHIJKLMNOPQRTVXYZ[\]^ܶɣܐ}ܣ}jɶܶܶjܣjɶɣ$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ h75CJOJPJQJ\aJ$h75CJOJPJQJRHc\aJ)^_abcdfgijklmnqrsuvw|~ɶɣɐɂ|xrxlf`xlxlrxrxrx|xlrxl`x h7@ h7@ h7@ h7@h7 h7@hDzCJOJPJQJaJ$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ h75CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ%Ͼp]$h75@CJOJPJQJ\aJ)h75>*CJOJPJQJ\aJwh$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ h75CJOJPJQJ\aJhDzCJ aJ hDz5\ h7@ h7@ h7@ h7@h7 h7@$               " ǰ܏܏܏||ܢiǢe܏܏Ǣh7$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJhDzCJOJPJQJaJ-h75>*CJOJPJQJRH\aJwh)h75>*CJOJPJQJ\aJwh h75CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ%" # & ' ) * + - . / 0 1 3 4 > ? A C E G H K L O P Q U V X Z ` a c     ܶܡxxܓrnhnh h7@h7 h7@$h75@CJOJPJQJ\aJhDzCJaJhDzCJOJPJQJaJ)h75>*CJOJPJQJ\aJwh$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ h75CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ&      " $ & * . 0 2 4 6 T V X ` b d h j l n p v x z | ~          h7@hDz h7@ h7@ h7@ h7@h7 h7@Tj  V J  <X.L00  Qgd7  Qdgd7 K^gd7$ ]^a$ Q Q   $ & ( * . : < B D F L N P T V r t v | ~         & ( * 8 : < > @ D F H J N R T hDz h7@ h7@ h7@ h7@h7 h7@ h7@TT V X Z ^ b f h l n r t            $ & , . 8 : < @ B D F H V X ^ ` h j p r v x hDz h7@ h7@ h7@ h7@h7 h7@V    "$*,.248:BDHJNPTV^`bprtxz|~hDz h7@ h7@ h7@ h7@ h7@ h7@h7T  "$(*,246:<>@BHJLPRVX`bdfhlnrt|~hDz h7@ h7@ h7@ h7@ h7@ h7@h7T "*,.BDFHNPVXnxz|~   "$&,.024:< h7@ h7@ h7@ h7@ h7@hDz h7@ h7@h7Q<>BDHJPRTX^`bdfhlnpxz|000 0 0000000 0*0,0002080:0<0B0D0F0J0 h7@UhDz h7@ h7@ h7@ h7@h7 h7@S and Middle Childhood/Music Ages 3-12 %Early Adolescence through Young Adulthood/Music Ages 11-18+ %Early and Middle Childhood/Physical Education Ages 3-12 %Early Adolescence through Young Adulthood/ Physical Education Ages 11-18+ %Early Adolescence/Science Ages 11-15 %Adolescence and Young Adulthood/Science Ages 14-18+ %Early Adolescence/Social Studies-History Ages 11-15 %Adolescence and Young Adulthood/Social Studies-History Ages 14-18+ Early Adolescence through Young Adulthood/World Languages Other Than English Ages 11-18+ %Early Childhood Through Young Adulthood/School Counseling Ages 3-18+ Jackson State University School of Lifelong Learning 3825 Ridgewood Road, Box 23 Jackson, MS 39211 Telephone: 601-979-8890 or 601-979-8724 Toll-free: 1-800-264-6234 J0L0N0P0R0X0Z0\0`0b0f0h0p0r0t0v0x0|0~00000000000000000000000000000000000011111 1 1111111$1&1(1.101216181X1\1^1b1d1f1n1p1v1x1 h7@ h7@ h7@ h7@ h7@h7 h7@hDzT08111H22334f4*5,555B6v6$ ^ a$$"^"a$$!^!a$$F f]F ^f`a$d ^gd7  & F ^  Qdgd7' d]' ^gd7 Qx1z1|111111111111111111111111111111111111222 2 222222 2$2&2(2224262>2@2B2F2H2J2L2R2T2X2Z2`2b2j2l2t2v2x222222222222222 h7@ h7@ h7@hDz h7@ h7@h7V22222222222222222222222222233 3333333 3"3$3(3*30323<3>3@3D3F3H3J3L3Z3\3b3d3j3l3r3t3v3x3z3~33333333333333333333333 h7@hDz h7@ h7@ h7@ h7@h7 h7@T3333333333333344 4 44444,42444B4D4F4H4J4N4P4R4Z4\4^4d4f444444444444444444444444444444445555 5"5(5*5,5hDzCJaJ h7@ h7@ h7@ h7@hDzh7 h7@ h7@M,50525456585:5<5@5B5F5H5T5V5\5^5f5h5j5l5n5p5r5t5|5~5555555555ɶܣܣܶܐ}jWܐ$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ$h75CJOJPJQJRHc\aJ$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ h75CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ"5555555555555555555555555555ɶɣܐܣ܂o\I$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJhDzCJOJPJQJaJ$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ h75CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ5555555566@6B6D6F6H6J6V6X6Z6\6^6b6d6h6j6l6n6p6ڶlڶYFǶ$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ*hNhN5@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJhDzCJOJPJQJaJ h75CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ$h75@(CJOJPJQJ\aJp6r6t6v6hDzCJOJPJQJaJ h75CJOJPJQJ\aJ$h75@CJOJPJQJ\aJ+ 0/ =!p"#P$% A 0/ =!p"#P$% P0 (A 0/ =!p"#P$% P0 (+ 0/ =!p"#P$% j 666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH66666666666666666666666666666666666666666666666666666666666666666p62 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ OJPJQJ_HmH nHsH tHD`D Normal1$CJ_HaJmH sH tH P@P  Heading 1 @&^05CJOJPJQJ\aJDA D Default Paragraph FontRiR 0 Table Normal4 l4a (k ( 0No List BB@B  Body Text ^D OJPJQJ88 List Paragraph:: Table ParagraphPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! 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