Cooperating Teacher Voucher Form

"*" indicates required fields

Teacher Candidate Name*

Semester*

Year*

Your Name*

Last 4 Digits of Your SSN (required for payment)*

Email*

School System Type*

*If you selected Private, you must have your school system complete and sign a W-9. Please email the completed W-9 to tiftfieldplacement@mercer.edu.

County*

**If you selected DeKalb County, you must have your school system complete and sign a W-9. Please email the completed W-9 to tiftfieldplacement@mercer.edu.

Other County*

If you selected "Other County", please list it here.

School Name*

School Address*

Street Address City State Zip Code

Type of Certification*

Please choose one of the following options.

I choose to receive the $50 payment. I understand that the $50 payment will be sent to the school system’s accounting/payroll office in my school system/county. All payments are deposited into your monthly payroll check. Any applicable deductions will be handled by that office.

I choose to receive the $150 voucher to be used as tuition payment for classes taken at Mercer University to renew my Georgia teaching certificate.

I choose to receive the $150 voucher to be used as tuition payment for classes taken at Mercer University to enroll in a graduate teacher education program at Mercer University.

I choose to transfer the voucher to a second party. (NOTE: the party accepting the voucher must be a professional educator who is a colleague at the Cooperating Teacher’s school or in the Cooperating Teacher’s school system.) No Mercer Student Teachers or paraprofessionals or office staff etc. will be allowed to obtain the voucher.

Transfer Recipient Name

Transfer Recipient Email

Last 4 Digits of Recipient's SSN (required for payment)

Transfer Recipient's School System

Transfer Recipient's School

Transfer Recipient's School Address

Street Address City State Zip Code

Transfer Recipient's Certification

Name

This field is for validation purposes and should be left unchanged.