Date:!!_____________!
Last!Name:! First!Name:! Middle!Initial:!
Location:! !Main!Campus! !Rolla! !Online! !Dual!Credit_______________! !Other_____________!
!!!!!!!!!!(name!of!instit u tio n )!! (indication!locatio n )!
!New!Employee!!!!! !Current!Employee! !ECC!Retiree!
Primary!Discipline:! Secondary!Discipline:!
Please&indicate&which&semester/class&start&date&for&this&instructor.!
!!Fall!____! !Spring!____! !Summer!____! !Winter!Intersession!____! !Other!____!
!!1
st
!8!weeks!! !!1
st
!8!weeks!
!!2
nd
!8!weeks! !2
nd
!8!weeks!
!!14!weeks!!!!! !!14!weeks!
!16!weeks!!!!! !!16!weeks!
Please&use&the&chart&below&to&indicate&the&courses&the&instructor&will&be&credentialed&to&teach.&Please&see&HLC&guidelines&
for&appropria te&creden tialing.&
Please&indicate&qualifications&specific&to&credentialed&discipline.&Highlight&degree/courses&to&support&discipline&credential&
on&attached&transcript.&
Course Name and Number (if approved for all courses
within the discipline, please indicate the subject and all,
i.e. history all)
Approved
Approved Provisionally (Please enter
deadline for completing required
credentials)
Institution
Degree, License/Certification
(include expiration date and
license/certification number)
Discipline
Indicate if credential is
for primary or secondary
discipline
Clear Form
Clear
Options
Adjunct Approval & Credentialing Form
!
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Comments!(Include!justification!for!using!tested!experience!to!credential)!
!
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!
!
!
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!
!
!!!Applicant!Meets!Qualifications!! ! ! !!!Applicant!Meets!Qualifications!Provisionally!
!
Comments!(Include!justification!for!provisional!credentials!and!necessary!requirements!and!timeline!to!move!
from!provisional!to!fully!credentialed)!
!
!
!
!
!
!
!
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The!following!documentation!must!be!included:!Transcript!to!support!credentialing,!Certifications/Licensure,!
and!Resume.!Additional!documentation!may!be!included!to!support!credential/recommendation.!
!
!
!
!
Dean!Signature/Date! ! !
!
!
!
!
!
!!Approved!!!!!!!!!!!!! !!Not!Approved!
!
_________________________________________!
Vice!President!Academic!Affairs!Signature/Date!! ! ! !
! ! !
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