2012 Application for the Occidental College TOPS Biology Professional Development Workshop - Phase I

Name:    Last First Middle 

Home Address City Zip

School    District

School Address City Zip

Home Telephone                              School Telephone

Cell (to contact you with updates regarding your equipment delivery or van vists)

E-mail Address Years Teaching Experience

Please Complete the table below for the upcoming school year (or current assignment if upcoming year
is unknown; please indicate if this is the case)

Science Course Name                        Grade Level                      # of Sections

What specific modern technology does your school make accessible to students?

I am applying to participate in the TOPS Biology Professional Development Workshop (Phase I)
and understand that full attendance at the workshop (M - F, 16 - 20 July 2012, 8 am - 5 pm) is required to receive the stipend.

I understand that access to TOPS owned biology equipment in my classroom
is contingent upon the successful completion of Phase I the of the program.

Signature (applicant): __________________________________________________ Date: ___________________

Principal or Department Chair Approval: Name (please print): _________________________________

Signature: __________________________________________________ Date: ___________________

Important: In addition to the online application you must return a signed hard copy of this application by 31 May 2012 to: TOPS Program (M-5), Occidental College, 1600 Campus Road, Los Angeles, CA 90041.

The online application puts you on the candidate list for the Phase I workshop, however, you cannot be considered for admission until the hard copy of the application is received by the TOPS office.

For questions, contact the TOPS office at (323) 259-2892 or by email at tops@oxy.edu

STOP! Before submitting this form please print out a copy for signing.  A signed copy MUST be mailed to the TOPS office before your application can be confirmed.