Fillable InstructorInformation-Part I - Instructor Information-Part I

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InstructorInformation-Part I - Instructor Information-Part I

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Winthrop University Professional Development Courses (WPDC)
Instructor Information Form
_________________________ ________________________ ____________
Last Name First Name Middle
Social Security Number _______________ Birthdate ________ Male___ Female ___
Ethnicity:
___ 1. Black (non-Hispanic) ___2. American Indian/Alaskan ___3. Asian/Pacific Islander
___ 4. International (non-resident Alien) ___ 5. Hispanic ___6. White (non-Hispanic)
_________________________________________ _____________________ _____________
Work Mailing Address: Street, PO Box City, State Zip
________________________________________ ________________________________________ _______________________________________
daytime phone number e-mail address fax number
College of Education
_ _WPDC___ ___________________________________________
College Dept. Rank (Professor, Associate Professor, Instructor, etc.)
_________________________________ __________________________________
Highest Degree Earned/Discipline/ Year Institution Highest Degree Received From
*Please submit a current professional resume with this form.
*All information must be completed for Winthrop University’s Student Information System
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InstructorInformation-Part I - Instructor Information-Part I

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Completed 8 February 2020

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