Form 402(Effective 11/12) Page 1 of 1
COMMISSION FOR INDEPENDENT EDUCATION
INSTRUCTIONAL AND ADMINISTRATIVE PERSONNEL
RETAIN A COPY OF THIS DOCUMENT IN FACULTY MEMBERS PERSONNEL FILE.
INSTITUTION DATA
Name: ID No.:
PERSONNEL DATA
Name:
Address (Residence):
City:
State:
Zip:
Business No.:
Residence No.:
Email:
Date of Initial Employment:
Primary responsibilities or courses taught:
Educational Background: (Institutions shall maintain evidence of the credentials that qualify faculty members)
School Name
Location (City, State)
Month/
Year
From
Month/
Year
To
Major Area
of Study
Certificate, Diploma, or
Degree Earned
Work Experience:
Employer
Address (Street, City,
State, Zip Code)
Month/
Year
From
Month/
Year
To
Job Title and Duties
Certifications/Licenses: (Attach a copy of faculty member’s credentials)
Occupational Licenses, Certifications, or Registrations Held
State Issued
Expiration Date
Have you been employed by, involved with, or in any way related with, other educational
institutions in Florida or any other state within the last ten (10) years?
Yes No If Yes, please provide specific details: name of school, location, your capacity and/or involvement.
Have you ever been known by any other name other than the one you are using on this
application?
Yes No If Yes, please explain.
Notarization
State of ____________ County of ____________
Before me, a Notary Public, personally known to me , or documentation
provided being duly sworn affirms that he/she will represent this institution in
good faith and in compliance with the laws of the State of Florida, and authorizes the Commission to
receive criminal justice information, as defined in Section 943.045, Florida Statutes, regardless of the
jurisdiction in which such information originated, pursuant to Section 1005.22(1)(H), Florida Statutes,
and affirms that the statements contained herein are true and correct.
Applicant Signature:
Subscribed and sworn to before me this day of , 20
Notary Public:
My Commission Expires: (SEAL)
530 West 49th Street,
Hialeah, FL 33012
5565
ASA College
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signature
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