Nominator Information

Date:

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1. Date:

Name of educator you are nominating:

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2. Name of educator you are nominating:

Email address of educator you are nominating:

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3. Email address of educator you are nominating:

Phone number of educator you are nominating (optional):

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4. Phone number of educator you are nominating (optional):

Has this person completed an application to participate in NYS test development  to the best of your knowledge?

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5. Has this person completed an application to participate in NYS test development  to the best of your knowledge?

Your Name:

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6. Your Name:

Your Position/Title

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7. Your Position/Title

Your Email Address:

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8. Your Email Address:

Your School/Institution:

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9. Your School/Institution:

Your School District (if applicable):

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10. Your School District (if applicable):

School/Institution Address:

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11. School/Institution Address:

City:

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12. City:

State:

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13. State:

Zip:

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14. Zip:

Your Work Phone:

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15. Your Work Phone:

Additional Comments:

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16. Additional Comments:

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