Fillable New Instructor Application (Saint Louis University)

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New Instructor Application (Saint Louis University)

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1818 Instructor Application P age 1
http://www.slu.edu/1818
NEW 1818 HIGH SCHOOL
ADJUNCT INSTRUCTOR APPLICATION
Revised May 2018
Applicant Name: ________________________________________________
First Middle Last
Application Date: ________________________________________________
Starting Academic Year: ________________________________________________
WELCOME
Congratulations! You are taking your first step to becoming an approved 1818
Advanced College Credit Instructor with Saint Louis University. Please fill out the
following parts of the application in full:
1. Personal Information (page 2)
2. Biographical Information (page 3)
3. Educational Background (page 4)
4. 1818 Course Offering Request (page 5)
5. Memorandum of Partnership (page 6)
6. Master Vendor Form (page 7-9)
In addition to this packet, your final full application should include:
1. a copy of your course syllabus created using the SLU 1818 Syllabus
Template,
2.
confirmation that your official transcripts have been requested to be
sent to the 1818 Program Office.
PLEASE EMAIL THIS APPLICAITON AND ADDITIONAL REQUIRED DOCUMENTS IN
PDF FORMAT TO 1818@SLU.EDU WHEN COMPLETE.
1818 Instructor Application P age 2
PERSONAL INFORMATION
Full Legal Name:
_______________________________________________________________________
Last First Middle Initial
Current High School:
________________________________________________________________________
Date of Birth: ______ / _____ / ________
Social Security Number: ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Personal Mailing Address:
Street Line 1
Street Line 2
City State Zip Code
School Email Address: _________________________ @ ____________________
School Phone Number: ________ - __________ - ___________ ext. _________!
Personal Email Address: _________________________ @ __________________!
Personal Phone Number: ________ - __________ - ___________ ext. ________!
1818 Instructor Application P age 3
BIOGRAPHICAL INFORMATION
Gender: ___Male ___Female ___Other!
Citizenship: ___US Citizen If other, country of origin: __________________!
Marital Status: ___Single ___Married ___Life Partnered
___Divorced ___Widowed ___Other
Religious Preference: ___Baptist ___Christian Orthodox ___Episcopalian
___Jewish ___Lutheran ___Methodist ___Muslim
___Presbyterian ___Roman Catholic ___Protestant
___No preference ___Other: ___________________!
Ethnicity: ___African American/Black ___Alaskan Native
___Asian ___Caucasian ___Hispanic
___Mexican American ___Native American
___Pacific Islander
___Other: ______________________________________
1818 Instructor Application P age 4
EDUCATIONAL BACKGROUND
Institution
Name
Graduation
Year
Associate’s
Degree
Bachelor’s
Degree
Master’s
Degree
Doctoral
Degree
ADDIT
IONAL COURSEWORK
Please list any additional post-graduate course work including certificate
programs, certifications, continuing education units, and additional non-
degree seeking graduate level coursework.
Type
(i.e. Certificate, CEU,
graduate course)
Institution
Name
Year
Completed
Course number/title,
certificate awarded, CEU
course name, etc.
1818 Instructor Application P age 5
1818 COURSE OFFERING REQUEST
To review eligible courses for 1818 credit, please visit the Course Listing
webpage on the 1818 Program website.
Please indicate below the course(s) you wish to offer and the semester in which
they will occur:
SLU Course Subject
and Number
(i.e. ENGL 1900)
SLU Credit Hours
(i.e. 3.00)
Semester Offered
(i.e. Fall, Spring, Both, Yearlong Course*)
* SLU courses taught across both high school semesters for one college semester’s credit are noted as yearlong course
offerings. The students will register and pay in the fall semester for the total credit hours of the course, however the final
grade is not posted until the spring semester when the cumulative total is calculated.
1818 Instructor Application P age 6
INSTRUCTOR MEMORANDUM OF PARTNERSHIP
As an active high school adjunct instructor in the 1818 Advanced College Credit Program, I understand the
requirements of active status and will uphold the 1818 Program Policies as outlined in the handbook, available
at http://www.slu.edu/1818, including but not limited to:
• Involvement: To ensure active participation the 1818 Program, 1818 Adjunct Instructors will:
encourage qualified students to register for appropriate courses, attend the annual Summer
Symposium and professional developments days, utilize SLU course management systems to oversee
their respective courses, remind students of deadlines related to the program, refer students to
necessary resources and rights guaranteed through SLU, and communicate with the 1818 Program
Office as needed.
• Academic Integrity: To ensure 1818 college credit courses are comparable to their on-campus
counterparts, 1818 Adjunct Instructors will: submit course syllabi in the appropriate SLU Common
1818 Syllabus Template annually to the program for review, supply annual assessments to the
appropriate SLU Faculty Liaison, enter grades in a timely manner each semester, accommodate SLU
Faculty Liaison and 1818 Program Office requests including site visits, ensure students have time to
complete SLU course evaluations each semester, and uphold Saint Louis University policies related to
academic offerings.
• Course Exclusivity: To ensure the integrity and authenticity of Saint Louis University courses and to
prevent confusion among dual credit students, 1818 Adjunct Instructors will: agree that Saint Louis
University is the exclusive dual credit partner for the specific college courses they are approved to
teach now and in the future through the program.
In agreement of th
ese requirements, I am aware of my eligibility to the following benefits:
• Status as an 1818 Adjunct Instructor of Saint Louis University,
• Graduate tuition scholarships,
• Discipline specific professional development,
• Direct access to designated SLU departments,
• Substitute teacher reimbursement to attend professional development,
• Annual training stipend,
• Access to SLU recourses including library access, database access, SLU logo usage, SLU email account,
Office 365, Google Apps, personal software discounts and downloads, and discounts at SLU’s Campus
Bookstore.
By signing the document, the individual agrees to uphold the various requirements of an active status
throu
ghout their tenure with Saint Louis University’s 1818 Advanced College Credit Program.
Failure to uphold the Memorandum of Partnership risks putting the individual, dual credit offering, and/or
partn
ership in a non-compliant status. A non-compliant status will result in discussion on the future
partnership with the program, ability to continue to offer specific dual credit courses, provisional standards to
be met to become active again, or the end of the dual credit partnership with Saint Louis University.
Individuals and partner high schools will be notified privately by the Program Director for issues of non-
compliance.
___________________________________ __________________________
Name (printed) Date
__________________________________
Signature (electronic acceptable)
click to sign
signature
click to edit
Updated 2/11/14
VENDOR MASTER
FORM
eSeeDPV
only
PLEASE TYPE OR PRINT
FORM
SLU Contact:
Vendor Information Required for Payment
REMIT TO:
Vendor name ____________________________
DBA ____________________________
Street/PO Box ____________________________
City, State, Zip ____________________________
Contact Name ____________________________
Telephone ____________________________
Fax ____________________________
Email Address ____________________________
Does this vendor accept American Express? [ ] Yes [ ] No
Is this company listed as a Certified Minority Vendor? [ ] Yes [ ] No
If Yes, please complete the attached Certification of Status Form
PAYMENTS TO NON-SLU PERSONS (place an X on the line to designate type)
Attorney/Legal Fees Prize or Award
Consulting/Other Services:___________________
Professional Entertainment
Dues/Subscriptions Refund
Expense Reimbursement Rent
Honorarium Services (type):______________
Licen
ses (Dr., Attorney, Car….) Speaker/Lecture Fee
Local Seminar/Conference/Registration Fee
Medical/Healthcare Services
Patient Study Non-Resident of US (Submit W8-BEN Form)
Pre-Pay Travel Expense Reimbursement
Pre-move
Personal Services/Honoraria
SLU DEPARTMENT INFORMATION
YOUR N
AME:__________________ PHONE:___________ EMAIL:_________________
VENDOR BANNER ID NUMBER:_________________
Complete form and return to eSeePay@list.slu.edu or fax 314-977-2298
Page 7
1818 Program
x
1818 Program 314-977-1818 1818@slu.edu
x
x
N/A
N/A
- -
@
Central Processing
Center
3545 Lindell Blvd, 3
rd
Floor
St. Louis, MO
63103
YOUR SLU CONTACT:______________________
VENDOR DIRECT DEPOSIT AUTHORIZATION AGREEMENT
Name:
Address:
City:
State:
Zip:
Phone:
Fax:
Remittance
Email:
A BLANK, VOIDED CHECK MUST BE ATTACHED.
If this is not available, please provide a letter from/on your bank’s letterhead stating the bank routing
Number and account name and number to be used for Direct Deposits.
Cancellation of your direct deposit must be made in writing. If any of your bank account numbers or
Transit numbers change, it will be necessary to complete a new Direct Deposit Authorization Agreement.
ACCOUNT FOR DEPOSIT (US BANKS ONLY)
Routing
Number:
Account
Number:
Type
of
Account:
Checking;
Savings;
Money
Market;
Other:
Bank
Name:
Branch
Location:
Address:
City:
State:
Zip:
We hereby authorize Saint Louis University to initiate credit entries to the account indicated above.
Signed
by:
Date:
Title:
Saint Louis University Use Only:
Vendor
#:
Page 8
1818 Program
Notification Direct Deposit Decision
I choose to: Opt-in for Direct Deposit
Opt-out of Direct Deposit
If you choose to op-in, please complete the banking form below.
If you opt-out a paper check will be mailed to your home
address.
@
-
-
N/A
Form W-9
(Rev. November 2017)
Department of the Treasury
Internal Revenue Service
Request for Taxpayer
Identification Number and Certification
▶
Go to www.irs.gov/FormW9 for instructions and the latest information.
Give Form to the
requester. Do not
send to the IRS.
Print or type.
See Specific Instructions on page 3.
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
2 Business name/disregarded entity name, if different from above
3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the
following seven boxes.
Individual/sole proprietor or
single-member LLC
C Corporation S Corporation Partnership Trust/estate
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)
▶
Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check
LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is
another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that
is disregarded from the owner should check the appropriate box for the tax classification of its owner.
Other (see instructions)
▶
4 Exemptions (codes apply only to
certain entities, not individuals; see
instructions on page 3):
Exempt payee code (if any)
Exemption from FATCA reporting
code (if any)
(Applies to accounts maintained outside the U.S.)
5 Address (number, street, and apt. or suite no.) See instructions.
6 City, state, and ZIP code
Requester’s name and address (optional)
7 List account number(s) here (optional)
Part I Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
backup withholding. For individuals, this is generally your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN, later.
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and
Number To Give the Requester for guidelines on whose number to enter.
Social security number
– –
or
Employer identification number
–
Part II Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid,
acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments
other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.
Sign
Here
Signature of
U.S. person
▶
Date
▶
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest information about developments
related to Form W-9 and its instructions, such as legislation enacted
after they were published, go to www.irs.gov/FormW9.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an
information return with the IRS must obtain your correct taxpayer
identification number (TIN) which may be your social security number
(SSN), individual taxpayer identification number (ITIN), adoption
taxpayer identification number (ATIN), or employer identification number
(EIN), to report on an information return the amount paid to you, or other
amount reportable on an information return. Examples of information
returns include, but are not limited to, the following.
• Form 1099-INT (interest earned or paid)
• Form 1099-DIV (dividends, including those from stocks or mutual
funds)
• Form 1099-MISC (various types of income, prizes, awards, or gross
proceeds)
• Form 1099-B (stock or mutual fund sales and certain other
transactions by brokers)
• Form 1099-S (proceeds from real estate transactions)
• Form 1099-K (merchant card and third party network transactions)
• Form 1098 (home mortgage interest), 1098-E (student loan interest),
1098-T (tuition)
• Form 1099-C (canceled debt)
• Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN.
If you do not return Form W-9 to the requester with a TIN, you might
be subject to backup withholding. See What is backup withholding,
later.
Cat. No. 10231X
Form W-9 (Rev. 11-2017)
Page 9
x
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New Instructor Application (Saint Louis University)

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Completed 26 July 2020

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