APPLICATION FOR INSTRUCTOR APPROVAL
1. Instructor’s Name _______________________________________________
Instructor’s Address _______________________________________________
_______________________________________________
Instructor’s Phone # _______________________________________________
Instructor’s Fax # _______________________________________________
2. Type of Activity (short course, publication, attendance at meeting)
3. Presentation method: (e.g. Lecture, Video, Distance Learning, etc.)
4. Outline, Abstract or description of activity.
5. Activity Duration (if applicable)
Contact Hours______ Days_______ Semester Hours______ Other _____
6. Course Title:
_________________________________________________________________
7. Hours Per Topic____________________________________________________
8. Code of Ethics_____________________________________________________
9. Location of Activity: _______________________________________________
10. Other Relevant Information:
_________________________________________________________________
_________________________________________________________________
11. Attach appropriate Resume and/or credentials supporting this request.
12. Requestor’s Signature___________________________________Date_________
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To be filled out
by Continuing Education Committee use: Instructor Approval:_______________________________________________________ Name of Reviewer (Print)___________________________________________________ Continuing Education Committee Member:__________________________Date_______ Signature |