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Resource Guide - Texas Workforce Commission

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1. Check One:<br />

Original Application*<br />

Additional Subjects*<br />

Resubmission in response to the<br />

Notice of Review<br />

Variance<br />

Affirmative Professional Conduct<br />

answer<br />

TEXAS WORKFORCE COMMISSION<br />

Career Schools and Veterans Education<br />

Instructor Application<br />

DEPT. USE ONLY<br />

Receipt #<br />

Fee Paid<br />

Date Paid<br />

Initialed by<br />

*Enclose $20 processing fee and Fee<br />

Sheet (PS-186) Authority for Data Collection: <strong>Texas</strong> Education Code Section 132.052<br />

Planned Use of Data: Determination of Instructor Qualifications<br />

Please type or print legibly.<br />

Today’s Date: ______/______/______<br />

2. CAREER SCHOOLS AND VETERANS EDUCATION INFORMATION<br />

School # _______________<br />

School Name ________________________________________________________________<br />

School Location (Physical Address) __________________________________________________________________________<br />

School Mailing Address (if different) _________________________________________________________________________<br />

School Phone # (_______) ____________________<br />

Toll-free # (_______) ____________________<br />

FAX # (______) ___________________<br />

E-mail___________________________________________________<br />

3. APPLICANT INFORMATION (ALL FIELDS ARE REQUIRED)<br />

Legal Name ______________________________________________________________________________________________<br />

First Middle Maiden Last<br />

Home Address _______________________________________________________________<br />

Telephone (_______) __________________<br />

Social Security # __________________ Date of Birth _______________ Date of employment as instructor _____________<br />

4. APPLICANT’S EDUCATIONAL HISTORY<br />

School Name<br />

City/State<br />

Date Begun<br />

(mm/yy)<br />

Date Ended<br />

(mm/yy)<br />

Major/Minor<br />

Diploma/<br />

Degree<br />

Awarded?<br />

(Yes or No)<br />

Secondary<br />

Education<br />

900+ Clock<br />

Hour Postsecondary<br />

Program<br />

Associate<br />

Degree<br />

Bachelor<br />

Degree<br />

Postgraduate<br />

Degree<br />

5. CURRENT CERTIFICATES OR OCCUPATIONAL LICENSES RELATED TO PROPOSED SUBJECTS<br />

Type ____________________________ Issued by _________________________________ # _________________________<br />

Type ____________________________ Issued by _________________________________ # _________________________<br />

Page 1 of 9<br />

PS-002<br />

PREVIOUS EDITIONS OF THIS FORM WILL NOT BE ACCEPTED REV 10/04

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