Eastern Suffolk BOCES
First Supervisory District
201 Sunrise Highway
Patchogue, NY 11772
ARTS IN EDUCATION
CONSULTANT APPLICATION
For programs offered
JULY 1, 2007- JUNE 30, 2008
The Suffolk County Arts-in-Education Advisory Council evaluates all applications for participation in BOCES
Shared Service/Artist-in-Education in Suffolk County School Districts. Recommendations made by the Council are
submitted to the New York State Education Department for approval. Completion of this application does not
automatically guarantee inclusion in catalogues or work in the schools. Please be sure to:




Submit recommendations with telephone numbers from two or more school administrators, principals, or teachers
attesting to the quality of the program and its validity as part of the educational process.
Specify ways in which the program(s) relate to the school curriculum and help meet NYS Learning Standards.
Include credentials, reviews by critics or other info related to the quality of the program(s).
Complete all sections and return attachments to:
Carol Brown, Administrative Coordinator
BOCES Arts-In-Education Services
Brookhaven Technical Center
350 Martha Avenue
Bellport, NY 11713
(631) 286-6989 (Phone)
(631) 286-6991 (Fax)
1. Personal Information
Name:
Raymond J. Lackey
Contact Person:
Raymond Lackey
Address:
Sweet Pines Apiary
Tel. No.:
631-567-1936 631-707-1544
City, State ZIP:
Bohemia, NY 11716-2176
Fax:
631-262-8053
Email Address:
lackeyray@tianca.com
Web Site:
www.tianca.com/tianca2.html
2. W-9 forms must be completed and signed annually
3. Describe each program available during 2007-08 school year on-line www.esboces.org/aie/
ALL INFORMATION INCLUDING COSTS OF PROGRAMS APPLY FOR THE DURATION OF THE FISCAL YEAR OF
APPLICATION
4. Attach copies of study guides and any printed materials appropriate to describing your program(s)
5. All applicants must list names of school districts for recommendation. Please include letters. Re-applicants
should submit at least 2 letters of recommendation.
School District
City/State
Contact Person
Telephone
Not Available
Not Available NY
Not Available
Not Available
Not Available
Not Available NY
Not Available
Not Available
NY
6. Moral Character Determination
Mark the response to the right of each question:
Individual
Company
(Art Org.)
1. Have you/anyone in your company ever resigned from a position rather than
Yes
face disciplinary action?
2. Has any disciplinary action been brought against you/anyone in your company
Yes
that resulted in you/your company being discharged from employment?
3. Did you/anyone in your company ever receive a discharge from the Armed
Forces of the United States which was other than "Honorable" or which was
Yes
issued under other than honorable circumstances?
No X
Yes
No
No X
Yes
No
No X
Yes
No
No X
Yes
No
Yes
No X
Yes
No
Yes
No X
Yes
No
Yes
No X
Yes
No
Yes
No X
Yes
No
4. Have you/anyone in your company ever been convicted of any crime (felony or
Yes
misdemeanor)?
5. Are you/anyone in your company now under charges for any crime (felony or
misdemeanor)?
6. Have you/anyone in your company ever forfeited bail bond posted to guarantee
your appearance in court to answer any charges?
7. Have you/anyone in your company ever had a teaching credential revoked,
suspended, or annulled?
8. Have disciplinary proceedings ever been initiated against you/anyone in your
company pursuant to New York State Education Law Section 3020?
If you answered YES to any of the questions above, provide specifics or an explanation for the response in the following
section. If you elect not to provide specifics or if such an explanation is insufficient, a confidential investigation will be
initiated. None of the above circumstances represents an automatic bar to being an independent consultant.
*Submit official copies of the court record including disposition of the case.
7. Use this section to answer any part of "Moral Character Determination" section
8. State former name/any other name(s) by which you were known: _____________________
DECLARATION
I declare, subject to the penalties of perjury that the statements made in this application (including statements made in any
accompanying papers) have been examined by me and to the best of my knowledge and belief are true and correct. I
further request and authorize any former employer, military records center, police, parole, and probation agencies, and
former school to provide to Eastern Suffolk BOCES and all information including, but not limited to information as to my
character, habits, work ability, and/or education. In consideration of compliance with this request, I hereby release and
discharge said institutions from any claims, liabilities, or damages
DATE: _________________
SIGNATURE:
_________________________