CERRITOS COMMUNITY COLLEGE DISTRICT
APPLICATION FOR FACULTY SERVICE AREA
Name: Date:
Last, First M.I.
Curr
ent Position: Division/Department:
In acc
ordance with the provisions of Education Code Sections 87743.1 through 87743.5, and the District policies/
procedures/requirements for Faculty Service Areas (FSA's), I hereby apply for the following FSA: (From the list of District Faculty
Service Areas, please list below the FSA for which you are making application)
FSA REQUESTED:
In the s
paces provided below, please indicate the information, which you believe, qualifies you for the requested FSA:
(Attach additional supporting documentation as may be required to verify your qualifications)
Educational Background/Degree(s)/Units in Subject Area(s):
Teaching Exp
erience and Recency:
Profession
al and/or Vocational Experience:
Other Qualifyi
ng Information: (Attach additional sheets if needed)
I here
by certify that all statements herein are true and factual to the best of my knowledge. I understand that this application is subject
to review and evaluation through established District procedures, and that the burden of proof for verifying that I meet any and all
qualifications/competency standards required for the requested FSA rests solely with me as the applicant.
Signature
An FSA application must be received in the Human Resources Office on or before February 15 in order to be considered as a
basis for reassignment in the event of reductions in force, program discontinuance, and/or lack of funding pursuant to the
provisions of Education Code, during the academic year in which the application is received.
FSA-1
(CONTINUED ON REVERSE SIDE)
SUMMARY OF ACTIONS ON APPLICATION FOR FACULTY SERVICE AREA
Human Resources Action: FSA application is received and forwarded to FSA Review Officer for further review and action
___________________ ________________________________________
Date Signature of Human Resources Manager
FSA Review Officer Action: FSA application is referred to an FSA Review Committee for further review and action.
___________________ ________________________________________
Date Signature of FSA Review Officer
FSA Review Committee Action: Approved Denied
If denied, reason(s) are as follows:
Signature of Committee Members:
FSA Review Officer Faculty Member (Discipline)
Faculty Member (Discipline Faculty Member (Other)
Instructional Dean/Area Administrator Date of Action
(Upon completion, FSA Review Committee returns the form to the FSA Review Officer)
Appropriate Vice President/Director of Human Resources (or Designee) Action: FSA Approved FSA Denied
(This step is required only if the FSA application is approved by the FSA Review Committee.)
If denied, reason(s) are as follows:
Date of Action Signature of Vice President (or designee) Signature of Director of Human Resources (or designee)
FSA Review Officer - Distribution of FSA Application:
Upon completion of the FSA Application review procedure, copies of FSA applications are to be distributed as follows: Original: employee's
personnel file, Copies to: employee, and Faculty Senate Office (retained by FSA Review Officer). (Signature/Date below indicates that
distribution of copies has been completed.)
Date Completed Signature of FSA Review Officer
Human Resources Office Recording:
FSA Code Faculty Service Area Effective Date Date Entered in Personnel File