INSTRUCTOR INFORMATION

Last Name

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* 1. Last Name

First Name

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* 2. First Name

Home Address

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* 3. Home Address

City

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* 4. City

State

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* 5. State

Zip Code

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* 6. Zip Code

Phone Number

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* 7. Phone Number

Alternate Phone Number

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* 8. Alternate Phone Number

Email Address

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* 9. Email Address

Term (Fall/Spring/Summer) and year of proposed course

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* 10. Term (Fall/Spring/Summer) and year of proposed course

Are you...

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* 11. Are you...

Are you...

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* 12. Are you...

If you answered "Yes" to any of the above questions, please provide the name(s) of the Departments you are/were affiliated with:

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* 13. If you answered "Yes" to any of the above questions, please provide the name(s) of the Departments you are/were affiliated with:

Instructor’s Biography. Please write a brief (50 word limit) biographical sketch. Tell us how you know your topic and how it interests you. Include your current title, if applicable. (Instructor biographies are subject to revision).

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* 14. Instructor’s Biography. Please write a brief (50 word limit) biographical sketch. Tell us how you know your topic and how it interests you. Include your current title, if applicable. (Instructor biographies are subject to revision).

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