<p>TO: NJ EXCEL E-MENTORS (INQUIRY GROUPS)</p><p>FROM: JOE POEDUBICKY, Ed.D. – NJEXCEL Program Coordinator</p><p>RE: PAYMENT FOR E-MENTORS</p><p>DATE: ______</p><p>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. </p><p>MENTOR NAME: ______SS#: ______</p><p>COMPANY NAME: ______TAX ID#: ______(If applicable) (If applicable) HOME ADDRESS: ______</p><p>______</p><p>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)</p><p>PER CANDIDATE: Models 1/2 $650; Model 3 $825 and Model 4 $400</p><p>CANDIDATE NAMES CANDIDATE NAMES</p><p>FOR NJ EXCEL OFFICE USE ONLY</p><p>TOTAL PAYMENT $______CHARGE TO: [ ] ______</p><p>TOTAL PAYMENT $______CHARGE TO: [ ] ______</p><p>TOTAL PAYMENT $______CHARGE TO: [ ] ______</p><p>DATE VOUCHER SUBMITTED: ______</p><p>APPROVED BY: ______DATE: ______</p><p>CHECK #: ______DATE: ______</p><p>Rev. 1/10</p>