2012 West Virginia School Service Personnel Employee of the Year

NOMINATION FORM 2012 West Virginia School Service Personnel Employee of the Year

(Please Note: All information must be typed.)

Name of Nominee County

Work Site Name

Name of Superintendent E-mail Address of Superintendent

Name of Principal or Supervisor E-mail Address of Principal or Supervisor

APPLICATION DEADLINE: May 1, 2012

Return to: Keith R. Burdette, Executive Director Office of Human Resources WV Department of Education Building 6, Room 264 1900 Kanawha Blvd., E. Charleston, WV 25305-0330 E-Mail: [email protected] Telephone: 304-558-2702 Fax: 304-558-0216 APPLICATION FORM 2012 West Virginia School Service Personnel Employee of the Year

(This form must be completed by Nominee. All information must be typed.)

Name Job Title

Home Phone Number E-mail Address

Home Address: Street/P.O. Box City State Zip

Name of Principal or Supervisor

Work Site Phone Number Work Site Fax Number

Work Site Address: Street/P.O. Box City State Zip

Brief description of current job responsibilities:

Total years employed by county Number of years at present work site

Respond to the following two (2) sections. Responses must be typed utilizing a font not smaller than 11 point. Begin each section on a new page. At the top of the page, specify the section number.

SECTION I: Attach a list of continuing education or training courses in which you have participated within the five-year period preceding the filing of this application. Indicate by whom the training was provided and/or if any certifications were earned. Be sure to list any situations in which you provided training to others. (Limit your response to one double-spaced page.)

SECTION II: List any community service activities, membership of organizations or committees (e.g., local school improvement council), or any awards, recommendations or recognition you have received from a school, district, organization or community within the five-year period preceding the filing of this application. (Limit your response to one double-spaced page.) STATEMENT OF NOMINATING COMMITTEE 2012 West Virginia School Service Personnel Employee of the Year

This form must be completed by the Nominating Committee. Please attach your response to this form and limit the response to three double-spaced pages. Responses must be typed utilizing a font not smaller than 11 point.

Based on the selection criteria, describe why this nominee should be selected as the West Virginia School Service Employee of the Year. Provide specific examples that demonstrate exemplary job performance and thereby promote student learning. Examples could include activities which create positive relationships with parents, students, coworkers and community members. You may also consider those activities which make schools safer, healthier, and more attractive.

Name of Nominee County

Work Site Name Name of Principal or Supervisor

Nominating Committee Members

APPLICATION DEADLINE: May 1, 2012

Return to: Keith R. Burdette, Executive Director Office of Human Resources WV Department of Education Building 6, Room 264 1900 Kanawha Blvd., E. Charleston, WV 25305-0330 E-Mail: [email protected] Telephone: 304-558-2702 Fax: 304-558-0216