Instructor Credentials Form

For Continuing Education Course Approval

Please complete all fields marked with an asterisk (*). Submit completed form along with supporting documentation.

Personal Information

Full Name*

Professional License Number(s)*

State(s) of Licensure*

Email Address*

Phone Number*

Years of Professional Practice*

Areas of Expertise*

Previous Teaching Experience

Course Title(s) to be Taught*

Relevant Qualifications for Course(s)*

Please attach the following required documents:

I certify that the information provided above is true and accurate to the best of my knowledge.

Signature*

Date*

Please submit completed form and supporting documentation to:

L.E.A.R.N Continuing Education
ATTN: Instructor Credentials
Email: [email protected]
Fax: (555) 555-5555