1. Faculty Qualifications Verification Summary
    1.       EDUCATION
    2. OTHER QUALIFICATIONS OR EXPERIENCE
      1. Licensures /Certifications
      2. Work Experience
      3. Other Qualifications or Experience (continued)
      4. Awards/ Recognitions
      5. Artifacts
      6. Other Evidence of Qualifications


Faculty Qualifications Verification Summary

Name:                Social Security Number:


Division:                Department:


Position:                Status:

_________________________________________________________________________________________

 


            EDUCATION


Degree:                Degree Field:


Institution:

 


Degree:                Degree Field:


Institution:

 


Degree:                Degree Field:


Institution:

 

 


OTHER QUALIFICATIONS OR EXPERIENCE

 


Licensures /Certifications

 

Certification:             Certification Source:


 

Valid Until:


Certification:             Certification Source:


 

Valid Until:

 


Certification:             Certification Source:


 

Valid Until:

 


Work Experience

 

 Summarize qualifying work experience. Include job descriptions, employers and calendar years of experience.


 

 

 

 

 

 

 

Form 2122/007 (5/12) (page 1 of 2)


 

 

Name:                Soc. Sec. Number:

 

_______________________________________________________________________________________

 

 


Other Qualifications or Experience (continued)

 


Awards/ Recognitions

 

 Describe qualifying awards and recognitions. Include relevant calendar years.


 

 

 

 

 


Artifacts

 

 Describe qualifying artifacts (drawings, diagrams, artwork, exhibits, etc.) Include relevant calendar years.


 

 

 

 

 


Other Evidence of Qualifications

 

 Describe other qualifying qualifications. Include relevant calendar years.


 

 

 

 

 

 

 

 

Courses approved to teach:


        ______________________________________      _________

       Division Dean               Date

 

   

 

                 

       ____________________________________________    _________

       Vice Chancellor for Academic Affairs         Date

 

 

 

Approved to Teach

Distance Learning Courses:

 

____________________________________________      __________

Dean, Distance Learning and Instructional Technology      Date

 

Form 2122/007 (5/12) (page 2 of 2)

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