Franklin West Supervisory Union Board

Date Filed: ________________

Last Name: __________________________________ First Name: _________________________

Address: _______________________________________________________________________

Town: ____________________________________ State: _________________     Zip: _________

School: ____________________________ Position: _________________   Grade: _____________

Endorsement(s) held
Level  (enter code and description, see reverse side for codes)          Expiration Year

    I

    II

Attach your goal(s) for professional development for the next relicensure cycle and indicate how they connect with the Five Standards for Vermont Educators.

At least one of your IPDP goals must connect to the school's initiatives for improving student learning. Place an asterisk (*) in front of the goal(s) that reflect the school's initiative(s) for improving student learning

Educator Signature _________________________________  Date___________________________

Date Received: ______ Board Action:  IPDP Approved: _______ lPDP Returned for Revision: ___________

Reasons for Revision:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

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__________________________________________ ________________
Signature of Board Chairperson upon Final Approval Date

Amendment Date(s) ___________________________________________________________________