The Central Western Zone of the
New York State Retired Teachers’ Association
BARRIE FLEEGEL MEMORIAL ACTIVE EDUCATOR GRANT
City ___________________________ Zip_____________
Contact phone_(____)_____________ Email________________________
Place of employment _______________________County______________
Professional responsibilities _______________________________________
Number of years in education ___________________________________
Name and contact information for your immediate supervisor or building principal
Pursuing: (please check)
Permanent Certification ___ Certificate of Advanced Study ___
Master’s ___ Doctorate___
College or University at ___________________________________
Educational field _________________________________________
Please answer the following questions using a separate sheet of paper.
1. Have you received any financial assistance for graduate work? Explain any financial hardships or special circumstances.
2. During your career as an educator, have you received any special awards or recognition? List any exemplary achievements.
3. Have you been involved with unpaid extra-curricular activities or special assignments at your educational facility?
4. Are you involved in any community service projects?
5. Why did you enter the field of education and what are your long-term goals?
Please forward your completed application to: Ann Czajkowski (email@example.com), 2311 Johnson Creek Rd, Barker, NY 14012 – postmarked by April 15th.