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:
Licensures /Certifications
Certification: Certification Source:
Valid Until:
Certification: Certification Source:
Valid Until:
Certification: Certification Source:
Valid Until:
Courses approved to teach:
______________________________________ _________
Division Dean Date
____________________________________________ _________
Vice Chancellor for Academic Affairs and Student Affairs Date
Form 2122/007 (4/22)
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