Application and Information

NOTICE: The stipend applicant will be required to upload a single PDF that contains documentation that demonstrates completion of the requirements of the stipend being sought.
A Request for Taxpayer Identification Number and Certification W-9 (https://www.irs.gov/pub/irs-pdf/fw9.pdf) will be required from each applicant.

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* What is your first name?

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* What is your middle name?

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* What is your last name?

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* What is your mailing address? (Line 1)

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* What is your mailing address? (Line 2 if needed)

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* What is your mailing address city?

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* What is your mailing address zip code?

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* What is your daytime contact phone number (XXX-XXX-XXXX)?

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* What is your workplace phone number (XXX-XXX-XXXX)?

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* What is your Arkansas Educator Licensure System Case ID number. (This can be located by going to https://adeaels.arkansas.gov/AelsWeb/Search.aspx, searching your name, locating your record, and then looking in the upper left hand corner of the web page in the box labeled "Case ID.")

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* What is your work email address?

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* I hold the 528 Endorsement on my Arkansas Educator's License and am requesting the $300.00 stipend.

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* I hold the 528 Computer Science endorsement, was the teacher of record for an approved course that had at least ten students enrolled for a fall semester, and am requesting the $850.00 stipend.

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* I hold the 528 Computer Science endorsement, was the teacher of record for an approved course that had at least ten students enrolled for a spring semester, and am requesting the $850.00 stipend.

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* Upload a completed Request for Taxpayer Identification Number and Certification W-9 (https://www.irs.gov/pub/irs-pdf/fw9.pdf)

PDF, JPEG, JPG, PNG file types only.
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* Upload, for educators seeking one or both of the $850.00 semesters stipends, a completed Computer Science Teacher Endorsement and Instruction Stipend Program Attestation (http://bit.ly/2ojPLYb). If you are seeking only the $300 stipend, please upload a copy of your license or screenshot of your AELS (http://adeaels.arkansas.gov/AelsWeb/Search.aspx) report.

PDF file types only.
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* I understand that I, as an individual holding an Arkansas Educator's License, am bound by The Code of Ethics for Arkansas Educators. Standard 3 states, "[a]n educator honestly fulfills reporting obligations associated with professional practices." Any submissions of this form that the ADE Office of Computer Science believes may be in violation of this standard will be reported to the ADE Professional Licensure Standards Board.

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* I understand that I am responsible proper reporting of any received stipends and any subsequent federal and/or state taxes. If I receive more than $600.00 in a calendar year, I will receive a 1099 from ADE.

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