Name _________________________________  School  _____________________________

School address  _____________________________________________________________

Home address  ______________________________________________________________

School phone  ________________________  School fax  _____________________________

email  _____________________________________________________________________

Home phone  _________________________  Social Security Number  ___________________

Professional experience:

____Number of years teaching

____Number of years as administrator

____Number of years in education

____Total number of years as educator

Include with this form:

• a brief statement describing your reasons for wanting to be a Utah Principals Academy Fellow
• a photograph suitable for printing
• a current resume
• completed Participation Agreement
• Superintendent’s Endorsement Form

Submit completed application by March 1, 2000 to:

Rosemary W. Baron, Director
Utah Principals Academy
Utah State Office of Education
250 East 500 South
Salt Lake City, Utah 84111