SECTION ONE: SE MANAGEMENT

DOCUMENTATION (DOCUMENT 1.4)

For Cambridge English Language Assessment Office use only
Cambridge ID Input to Database by (initial and date)

SPEAKING EXAMINER NOMINATION FORM

PLEASE REMEMBER TO:
 submit completed forms to your RTL/PSL AT LEAST 6 WEEKS before the nominee is required to examine
 if you intend to post the form, please write legibly in black ink and block capitals
 refer to the Notes to Accompany Speaking Examiner Nomination Forms when completing this form
The information on this form will be kept securely by Cambridge English Language Assessment and used only for the purpose of
speaking examiner arrangements.

1: NOMINATION DETAILS
To be completed by the CEM

Centre Name British Council Venezuela Centre Number VE001

Please put an X in the appropriate box(es) to indicate which level(s) the nominee is being nominated for
(please ensure that Section 3 corresponds)

KET PET FCE CAE CPE ILEC ICFE

BEC P BEC V BEC H YLE S YLE M YLE F

Date when nominee is required to begin examining if approved:

2: PERSONAL DETAILS
To be completed by the nominee or by the CEM on behalf of the nominee
Title First name(s) Surname

Date of birth *mandatory field Gender Nationality First Language Former Surname (if applicable)
Day Month Year Male Female

Postal address

Post / Area Code Country

Home Telephone Work Telephone

e-mail *mandatory field Mobile Telephone

3: INDUCTION AND TRAINING DATES

To be completed by the CEM or Team Leader / SETC
Day Month Year Day Month Year
SE Induction completed SE Induction completed (YLE)
Level / Qualification Training completed Level / Qualification Training completed
Day Month Year Day Month Year

Day Month Year Day Month Year

Day Month Year Day Month Year

Revised June 2013

 Name of nominee

4: HIGHER EDUCATION AND QUALIFICATIONS

To be completed by the nominee or by the CEM on behalf of the nominee
Degrees / Certificates achieved (include subject) Dates attended Education Institute (Name / Location)

UCLES / RSA UCLES / RSA Other TESOL

CTEFLA / COTE / CELTA DTEFLA / DOTE / DELTA (please specify)

5: ENGLISH LANGUAGE PROFICIENCY

This must be completed if English is not the nominee’s first language
Highest qualification achieved (and grade) Date awarded Awarding body

Yes No
Was the Cambridge English Language Assessment If so, which band was
English Language Proficiency Interview conducted? achieved?

6: PRESENT AND PREVIOUS EMPLOYMENT

To be completed by the nominee or by the CEM on behalf of the nominee
Date (From /To) Employer (Name / Location) Duties (include details of ages, levels and nationalities taught)

TOTAL NUMBER OF YEARS AS AN EFL/ESOL TEACHER

7: OTHER EXAMINING EXPERIENCE

To be completed by the nominee or by the CEM on behalf of the nominee
Date (From /To) Subject / Scheme Examining / Validating Body

Yes No
Do you currently work for any other
providers of ESOL examinations and If so, please state which
tests?

Revised June 2013

 Name of nominee

8: ADDITIONAL INFORMATION
To be completed by the PSL/RTL, nominee or the CEM as appropriate
Please add below any further information relevant to this nomination, with associated dates.
For example: PSL/RTL note relating to MPRs, experience with Young Learners if being nominated for YLE (please give
age groups), experience in teaching Business English if being nominated for BEC etc...

9: NOMINEE DECLARATIONS
To be completed by the nominee: All nominees must sign the first two declarations; nominees for YLE must also sign the third.
I give permission for Cambridge English Language Assessment to make recordings of Speaking tests and RITCME events in which I
participate as part of my work for Cambridge English Language Assessment, and to make copies or transcriptions of such recordings. I
understand that the recordings will be used only for the following purposes:

a) analysis for research and validation internally within Cambridge English Language Assessment, including second marking and
examiner monitoring for quality control;
b) externally by approved researchers, subject to strict conditions consistent with accepted research practice in the field, who may
make manual or electronic copies;
c) parts of recordings or parts of transcriptions may be used for TL and SE induction, training, coordination and monitoring events
and activities and for presentation at professional development events such as training seminars and conferences.

I hereby waive any right to be identified as the author of the work.

Day Month Year
Signature / Name of Nominee:

I agree that if approved as a Cambridge English Language Assessment Speaking Examiner, I will comply with all requirements for
examining conduct, confidentiality and co-operation as set out in the relevant Instructions to Speaking Examiners.

I confirm that I have basic IT skills (including word processing, email, and internet) and am able to access the internet routinely via
broadband connection. (Cambridge English Language Assessment Speaking Test materials are made available to Speaking
Examiners via the internet.)
Day Month Year
Signature / Name of Nominee:

FOR YLE SPEAKING TESTS ONLY: I hereby certify that in undertaking the position of Speaking Examiner for the Cambridge Young
Learners Tests, I understand that I shall be responsible for examining children between the ages of 7 and 12 on a one-to-one basis. I
declare that I am a fit person to undertake such work and that I comply with current local legislation relating to working with children.
Day Month Year
Signature / Name of Nominee:

10: AUTHORISATION
To be completed by the CEM, TL / SETC and RTL / PSL
 Once all relevant sections have been completed, the form must be passed to the TL/SETC who will sign, to
signify approval, and pass it to the RTL/PSL.
If the form is being sent electronically, then typed names (with dates) are acceptable in place of signatures. For YLE
nominations, you must post or e-mail a scan of the original signed form to Cambridge English Language
Assessment.
I certify that this nominee meets the Minimum Professional Requirements as Speaking Examiner for the specific qualifications indicated
in Section 1.
Day Month Year
Signature/Name of CEM:
Day Month Year
Signature/Name of TL/SETC:
Day Month Year
Signature/Name of RTL/PSL:

The RTL/PSL must check the form, sign it to indicate approval and send to Cambridge English Nominations:
By e-mail: [email protected]
By Post: Cambridge English Examiners & Pretesting Administration Unit, 1 Hills Road, Cambridge, CB1 2EU, United Kingdom

Revised June 2013