FROM: JOE POEDUBICKY, Ed.D. NJEXCEL Program Coordinator

TO: NJ EXCEL E-MENTORS (INQUIRY GROUPS)

FROM: JOE POEDUBICKY, Ed.D. – NJEXCEL Program Coordinator

RE: PAYMENT FOR E-MENTORS

DATE: ______

In an effort to facilitate the payment process, please complete the form below and e-mail it to Joe Poedubicky ([email protected]) or fax to (609) 860-2999. PLEASE NOTE: Two (2) payments are made for Models #1 and #2; and three (3) payments are made for Model #3; Payments will be processed within 45 days following submission of this form; and Final Summative Assessment Report(s) for all candidates in your Inquiry Group must be submitted before your final payment can be processed.

MENTOR NAME: ______SS#: ______

COMPANY NAME: ______TAX ID#: ______(If applicable) (If applicable) HOME ADDRESS: ______

______

STIPEND(S) TO BE PAID COHORT, MODEL NUMBER OF RATE OF PAY TOTAL PYMT #1 PYMT #2 PYMT #3 LOCATION INQUIRY GROUP PER PAYMENT (6 MOS) (12 MOS) (MODEL #3 C-CENTRAL CANDIDATES CANDIDATE DUE ONLY; N-NORTH 18 MOS)

PER CANDIDATE: Models 1/2 $650; Model 3 $825 and Model 4 $400

CANDIDATE NAMES CANDIDATE NAMES

FOR NJ EXCEL OFFICE USE ONLY

TOTAL PAYMENT $______CHARGE TO: [ ] ______

DATE VOUCHER SUBMITTED: ______

APPROVED BY: ______DATE: ______

CHECK #: ______DATE: ______

Rev. 1/10