Fillable DE Instructor Information Form (Virginia Western Community College)

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DE Instructor Information Form (Virginia Western Community College)

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1
DUAL ENROLLMENT INSTRUCTOR INFORMATION FORM
Information collected will be used to determine qualifications and credentials for teaching dual enrollment courses for Virginia
Western Community College (VWCC).
PERSONAL INFORMATION:
Name: ________________________________________________________________________
Home Address: _________________________________________________________________
City: ___________________________ State: ____________ Zip Code: __________
Primary Contact Number: _____________________________ Other Contact Number: ____________________
E-mail Address
: __________________________________________________________________
Have you ever taught as a Virginia Community College System (VCCS) instructor or dual enrollment instructor in the
past? _______ YES _______ NO If so, which VCCS College? ________________________________
If you have ever applied as a student to a VCCS college or worked as a faculty member or dual enrollment instructor,
please reference your VCCS EMPLID Number: __________________
DUAL ENROLLMENT LOCATION (Please include the school information where you would like to teach VWCC
dual enrollment classes)
Name of School Division: _____________________________________________________________
Name of High School: ________________________________________________________________
High School Address: _________________________________________________________________
___________________________________________________________________________________
High School Phone Number: ___________________________ High School Administrator: __________________________
Dual Enrollment Course Content Area: _______________________________________________
VWCC DUAL ENROLLMENT OFFICE
F125C Fishburn Hall
3093 Colonial Ave SW
Roanoke, VA 24015
540-857-7235
540-857-6478 (FAX)
2
EDUCATIONAL HISTORY: Starting with y our most recent educational experience, please provide your
educational history, including high school, trade, college and graduate school. Please submit an official
transcript from each college that you have attended.
Name of School: _________________________________________________________________________
City/State: ______________________________________________________________________________
Level of Course Work: _______ Graduate ______ Undergrad ______ Trade School _____ High School
Major and Degree Earned: __________________________ or Number of Hours Completed ___________
Major Area of Study: ______________________________________________________________________
Name of School: _________________________________________________________________________
City/State: ______________________________________________________________________________
Level of Course Work: _______ Graduate ______ Undergrad ______ Trade School _____ High School
Major and Degree Earned: __________________________ or Number of Hours Completed ___________
Major Area of Study: ______________________________________________________________________
Name of School: _________________________________________________________________________
City/State: ______________________________________________________________________________
Level of Course Work: _______ Graduate ______ Undergrad ______ Trade School _____ High School
Major and Degree Earned: __________________________ or Number of Hours Completed ___________
Major Area of Study: ______________________________________________________________________
Name of School: _________________________________________________________________________
City/State: ______________________________________________________________________________
Level of Course Work: _______ Graduate ______ Undergrad ______ Trade School _____ High School
Major and Degree Earned: __________________________ or Number of Hours Completed ___________
Major Area of Study: ______________________________________________________________________
Please add additional sheets if needed:
3
INDUSTRY CREDENTIALS: Please list all current professional licenses or industry credentials. You may be asked
to provide photocopies of some of the credentials.
License/Credential ___________________________________________________________________________
Issuing Agency: _____________________________________ Expiration Date: __________________________
License/Credential ___________________________________________________________________________
Issuing Agency: _____________________________________ Expiration Date: __________________________
License/Credential ___________________________________________________________________________
Issuing Agency: _____________________________________ Expiration Date: __________________________
License/Credential ___________________________________________________________________________
Issuing Agency: _____________________________________ Expiration Date: __________________________
INDUSTRY EMPLOYMENT HISTORY: For some credentialing requirements, the VCCS may require industry
experience in the content field. Please list industry related positions held post high school and begin with the
most recent. You do not need to include teaching/education related positions here. We may need to contact
the employer to verify trade and industry employment length.
Employer Name: _________________________________________________________________________
Employer Address: ________________________________________________________________________
Name of person who can best evaluate your work: _______________________________________________
Phone: ________________________________ was this position: _____ Full Time _____ Part Time
Job Title: ______________________________________ Start Date: __________ End Date: __________
Job Duties: __________________________________________________________________________________
____________________________________________________________________________________________
Reason for Leaving: ___________________________________________________________________________
Employer Name: _________________________________________________________________________
Employer Address: ________________________________________________________________________
Name of person who can best evaluate your work: _______________________________________________
Phone: ________________________________ was this position: _____ Full Time _____ Part Time
Job Title: ______________________________________ Start Date: __________ End Date: __________
Job Duties: __________________________________________________________________________________
____________________________________________________________________________________________
4
Reason for Leaving: ___________________________________________________________________________
Employer Name: _________________________________________________________________________
Employer Address: ________________________________________________________________________
Name of person who can best evaluate your work: _______________________________________________
Phone: ________________________________ was this position: _____ Full Time _____ Part Time
Job Title: ______________________________________ Start Date: __________ End Date: __________
Job Duties: __________________________________________________________________________________
____________________________________________________________________________________________
Reason for Leaving: ___________________________________________________________________________
Employer Address: ________________________________________________________________________
Name of person who can best evaluate your work: _______________________________________________
Phone: ________________________________ was this position: _____ Full Time _____ Part Time
Job Title: ______________________________________ Start Date: __________ End Date: __________
Job Duties: __________________________________________________________________________________
____________________________________________________________________________________________
Reason for Leaving: ___________________________________________________________________________
ADDITIONAL INFORMATION:
Please use this space for any additional information you think would help us evaluate your application,
including training, seminars, workshops, and special achievements or specialized skills:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
5
INSTRUCTOR AGREEMENT:
I certify that the information provided in this Dual Enrollment Instructor Information Form is true and complete.
I accept the Mission, Vision, Core Values and Instructional Goals of Virginia Western Community College
(VWCC) as defined in the VWCC catalog.
I understand that I am responsible for providing instruction that will allow the student to complete the learning
objectives identified in the VWCC Course Outline.
I understand that I will be required to submit various course or student documentation required by the college.
I understand that acceptance, as a dual enrollment instructor is not an offer of employment by VWCC and that
I am not entitled to any benefits provided by the Virginia Community College System (VCCS).
I understand that all information on this form is subject to verification. I consent that you may contact
references, current and former employers and educational institutions listed.
I understand that official transcripts of all college coursework and photocopies of any industry certifications or
professional trade licenses must be provided to the VWCC Dual Enrolment Office in order to become a dual
enrollment instructor.
Signature: _______________________________________________ Date: ______________________
CREDETNIALING CHECK LIST (Please provide the following items)
______ Instructor Information Form
_____ Resume
_____ Official College Transcripts
_____ Photocopies of current industry certifications and/or professional licenses
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DE Instructor Information Form (Virginia Western Community College)

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Completed 24 July 2020

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