Encore Campus 2012-2013 Course Proposal Question Title * 1. Instructor Name: Question Title * 2. Phone (nnn-nnn-nnnn): Question Title * 3. Email: Question Title * 4. Credentials BA BFA BS MEd CFP DR ESQ JD LISW LMT MA MBA MDiv MFA MS MSN None PhD RN Tutor Other (please specify) Question Title * 5. If you are a new instructor or if you have a new address, please complete the following (You only need to enter this information once): Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code: Question Title * 6. How did you hear about our program? Returning Instructor Recruted by Center for Aging Initiatives Student Family/Friends Website Flyer Adjunct Office Other (please specify) Question Title * 7. Is this a new course? Yes No Next