Request for National Board Candidate Support (2022-23 Cycle)

This form is for National Board candidates to request support from a qualified Professional Learning Facilitator (PLF). Based on the needs identified, you may be asked to complete an application to facilitate placement with a mentor or cohort.

Name Name * First Last
Email (select email address you check frequently; non-school may be preferrable for year-round updates) *
Preferred Phone Preferred Phone * - ### - ### ####
Which best describes you as a candidate? *

Which best describes you as a candidate? I am a candidate pursuing my initial certification. I am an NBCT currently seeking to maintain my certificate.
In what year did you initially certify?
In what year will your current National Board Certification expire?
Current School (example Smith Elementary School)
School District *

If you are in a private school or similar setting, please identify the city or county in which the school is located.
If you are a Maintenance of Certification candidate (current NBCT) who will be "borrowing" a class to complete certification, indicate the district in which you will complete your National Board work.
Please select your NBCT certificate area. *
Which best describes your progress as a candidate?

Which best describes your progress as a candidate? I have registered, but I have not purchased any components. I have purchased component(s), but I have not yet submitted any. I have submitted one or more component previously.
Optional: Regarding components you have previously submitted, are you considering resubmitting a component because you did not achieve a passing score?

Optional: Regarding components you have previously submitted, are you considering resubmitting a component because you did not achieve a passing score? Yes. No. I don't know.
Which components are you working on in the current cycle (2022-23)? Select all that apply.

Which components are you working on in the current cycle (2022-23)? Select all that apply. Component 1: Content Knowledge Component 2: Differentiation in Instruction Component 3: Teaching Practice & Learning Environment Component 4: Effective & Reflective Practitioner
What type of support are you seeking? (Select all that apply.) *

What type of support are you seeking? (Select all that apply.) a one-on-one mentor who will read components and provide feedback a cohort to provide fellowship & support through regular meetings workshops that focus on a specific components mentorship related to re-submitting a component on which I was unsuccessful training and/or support to advocate for National Board Certification in my school or school district
Are you a member of any of these recognized National Board Affiliate Networks? (check all that apply) *

Are you a member of any of these recognized National Board Affiliate Networks? (check all that apply) SEVA NBCT Regional Network Virginia Education Association (VEA) Virginia NBCT Network I am not a member of any of these organizations.
If you are a VEA member, please identify your local affiliate.
Please read and sign your acknowledgement of the following information:
I understand that working with a PLF does not guarantee I will achieve certification or maintain my certificate. I also recognize that as NBCTs and PLFs, the individuals who support candidates are bound by a code of ethics that guides their methods and feedback they provide. I understand that the components developed in the certification process must represent my own work, and no matter what coaching or feedback is provided, I must make my own decisions regarding my certification process and component submissions.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.