UFT

Today's date MM / DD / YYYY
Name First Last
E-mail address (non-DOE)
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home phone number ### - ### - ####
Cell phone number ### - ### - ####
File number
Number of years in teaching
Tenured
Yes No
Current license area
Current work assignment
District
Current school
Current school address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
School phone number ### - ### - ####
Name of current principal
If you were rated ineffective or developing last June, or unsatisfactory in previous years, please specify the date(s)and school(s) or site(s). (This refers to the annual rating, not specific observations or letters.)
Why do you feel your classroom competence would benefit from Peer Intervention? Is your decision based on your having received an ineffective, developing or unsatisfactory rating or formal warning? If so, what reasons were given for this rating or warning? Please explain.
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