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Please print or type, fill out completely and send
application with any other pertinent information to:
Klamath Community College
K12 Support Coordinator
7390 S 6th Street
Klamath Falls, OR 97603-7121
Date: _____________
High School where Dual Credit will be taught: ____________________________________
KCC Dual Credit Courses proposed to be taught:
_________________________________________________________________________________
_________________________________________________________________________________
PERSONAL INFORMATION
Last Name: _________________________ First Name: ____________________ MI: _____
Street Address: _______________________________________________________________
City: ______________________________ State: _______ Zip Code: ___________________
Home Telephone: ____________________ Cell phone: _____________________________
Email ___________________________________ Date of Birth ____________________________
EDUCATION and TRAINING
University/College: ____________________________________________________________
Course of Study: ___________________ Credits Completed: ____ Degree Rec=d: _____
University/College: ____________________________________________________________
Course of Study: ___________________ Credits Completed: ____ Degree Rec=d: _____
University/College: ____________________________________________________________
Course of Study: ___________________ Credits Completed: ____ Degree Rec=d______
Business/Trade School: _______________________________________________________
Course of Study: _________________________ Length of Course: __________________
Certificate/License Rec=d: _____________________________________________________
Dual Credit Teaching History
List any other colleges or universities for which you have taught dual credit
courses along with the courses taught:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
EMPLOYMENT HISTORY RELATED TO THE COURSES YOU
PROPOSE TO TEACH FOR DUAL CREDIT
Most Recent Employer: _______________________________________________________
Address: _____________________________________ Phone #:______________________
Position: ___________________________
Description of Duties: ________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Dates of Employment: From _________________ to __________________
Former Employer: ____________________________________________________________
Address: _____________________________________ Phone #:______________________
Position: ___________________________
Description of Duties: ________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Dates of Employment: From _________________ to __________________
ADDITIONAL INFORMATION
List any other training, licenses, certificates, or other skills that add to your
candidacy for this position:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
APPLICANT’S CERTIFICATION AND AGREEMENT
By my signature, I certify that the facts set forth in this documentation for teaching dual
credit courses are true and complete to the best of my knowledge. I agree that if the information
given in my application, resume, or any other materials is found to be false in any way, it shall be
considered sufficient cause for denial or termination of teaching dual credit courses with Klamath
Community College.
I authorize past employers, references, and other applicable persons to give KCC
representatives any information regarding my employment, education, character, and any other
general information deemed necessary to assess my qualifications for teaching dual credit courses
and I hereby release these individuals from any and all liability or damages arising from furnishing
requested information.
I have attached/will send copies of transcripts relating to my education that
qualify me to teach a dual credit course at KCC.
Signature: _____________________________________________ Date: ______________________________
Klamath Community College is an equal opportunity educator and employer.
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Completed 26 July 2020

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