Certificate in College & University Teaching

1. BSU ID number

2. Please provide the following contact information

First Name
Last Name
Middle Initial
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Home Phone
E-mail

3. Please describe your educational history

        Year(s):

        Institution: 

         Program/Major: 

        Degree Earned: 

Year(s):

Institution: 

Program/Major: 

Degree Earned: 

4. Current Student Status, if applicable:

        Degree Sought:  

        Date Expected:  

        Institution:  

        Program/Major: 

        Advisor name and contact information:

5. Current Employment Status, if applicable

        Job Title: 

        Institution or Company: 

        Department: 

6. Please describe any teaching or teaching-related experience(s) you have:

7. What are your primary objectives in seeking to obtain a Certificate in College & University Teaching?

8. Do you plan to pursue the Certificate part-time or full-time?

Part-time
Full-time

9. Please provide the names, mailing addresses, email addresses, and phone numbers for three people willing to serve as references for you:

        Reference 1:

Name
Title
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
E-mail

        Reference 2:

Name
Title
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
E-mail

        Reference 3:

Name
Title
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
E-mail