SMI Teacher Information Form

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Download an opendocument format copy of this form

Name of cluster ePrincipal here
Mobile: insert cellphone number here
Skype: insert skype contact here

Insert Cluster logo here

South Island Cluster Scholarship Mentoring Initiative 2009:
  • Mentor teachers information form

The purpose of this form is to gain information which will help planning this year’s SMI programme. Please complete and email ( or fax (insert fax number here) back to cluster ePrincipal

Mentor teacher’s Name:
Email address:
Phone (School):
SMI subject:
Preferred time for VC tutorial:
- other available days/times


Specific PD/training requests:

e.g using the VC;

--use of OLE (Moodle);

--teaching online

--teaching scholarship


MoE Number (on payslip):
Alternatively, I would prefer to be paid (on invoice) to the follow GST registered account
Yes / No
Account Name: GST No:
Bank Account No:

Insert signature and date here