Encore Campus 2012-2013 Course Proposal Survey

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1. Instructor Name:

Instructor Name:

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2. Phone (nnn-nnn-nnnn):

Phone (nnn-nnn-nnnn):

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3. Email:

Email:

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4. Credentials

Credentials BA BFA BS MEd CFP DR ESQ	JD LISW LMT MA MBA MDiv MFA	MS MSN None PhD RN Tutor
Other (please specify)

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):

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:
ZIP/Postal Code:

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6. How did you hear about our program?

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)

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7. Is this a new course?

Is this a new course? Yes

No