Five-Year Certification Renewal Plan



|District Plan of Professional Growth Activities for Renewal of 5-Year Certification |

|2012 - 2017 |

| |

|Revised: 7/20/2012 |

TABLE OF CONTENTS

I. OVERVIEW 3

A. Positions Requiring Certification 3

B. Types of Certification And Recertification Guidelines 3

II. GENERAL DEFINITIONS 4

III. OBJECTIVES 4

IV. POLICY 4

V. REQUIREMENTS 4

A. Credit Limits 5

B. Time Limits 5

C. Prior Approval For Renewal Activities 5

D. Guidelines For Use of Professional Growth Activities 5

VI. APPROVED CERTIFICATION RENEWAL ACTIVITIES 5

i. Academic Coursework 5

ii. Continuing Education 5

iii. Work Experience 6

iv. Approved Professional Growth Activities 6

A. Workshop, Conference, Seminar, Webinar 6

B. Teaching 6

C. Professional Service 6

D. Professional Speaking 6

E. Cross-Training 7

F. Alternate Assignment 7

G. Literary Accomplishment 7

H. Leadership Role 7

I. Educational Innovation 7

J. Consultant/Evaluator 7

K. Research and Development 8

L. Technical Updating 8

M. National and International Study Tours 8

N. Mentor/Professional Development Team Member 8

O. Community Service 8

P. Occupational Certification/Licensure 8

Q. Grant Writing 8

R. Service Learning 8

S. Miscellaneous 9

VII. CERTIFICATION APPEALS PROCESS 9

A. Purpose 9

B. Procedure 9

Request for Appeal to the District Certification Officer 9

Request for Appeal to the District Certification Committee 9

Request for Appeal to the State Certification Committee 9

FORMS 10

I. OVERVIEW

The Wisconsin Administrative Code TCS 3, more commonly known as the Wisconsin Technical College Certification Code, calls for a district plan of recertification activities. In compliance with the code, the above-referenced plan was approved by the Gateway President on March 27, 2012 and the WTCS State Certification Committee on June 5, 2012.

A. Positions Requiring Certification

The following categories of employees require WTCS certification:

▪ Instructor – An individual who has responsibility for the delivery of classroom instruction.

▪ Instructional Supervisor – An individual who supervises certified staff and/or manages one or more instructional

programs.

▪ Instruction-Related Supervisor – An individual who supervises instructional-related staff.

▪ Instructional Administrator – An individual who has responsibility for administering the overall educational program

of the district or for an assigned portion of the overall educational program of the district.

▪ Instructional-Related Administrator – An individual responsible for administering the overall instructional-related

program of the district.

▪ Counselor – An individual responsible for counseling students on vocational/career and personal concerns through the

use of interview, test, and other techniques based on modern counseling principles.

▪ Librarian – An individual responsible for operating and managing a library and/or library services program.

B. Types Of Certification And Recertification Guidelines

Five-Year Certification – Indicates a person has completed all of the requirements for certification. Applies to all Gateway full-time and adjunct personnel filling positions that require certification.

Requirements for Renewal of Five-Year Certification – The Five-Year Certificate may be renewed if individuals have documented evidence of completion of six semester credits, or two months of appropriate occupational experience, or other approved district in-service activities, or a combination thereof.

Provisional Certification – Indicates a person is working toward the Five-Year Certificate. Applies to Gateway full-time personnel filling a position that requires certification.

Requirements for Renewal of Provisional Certification – The initial Provisional Certificate shall be valid for three years and may be renewed for additional two-year periods if during the provisional certification period preceding the expiration date, the person makes progress toward meeting the requirements of a Five-Year Certificate by completing six semester credits or equivalent approved district in-service activities, and documented evidence of activities is submitted.

Part-Time Provisional Certification – Indicates a person working toward the Five-Year Certificate. Applies to all Gateway adjunct academic and occupational instructional staff teaching more than two program courses per renewal period.

Requirements for Renewal of Part-Time Provisional Certification – The initial Part-Time Provisional Certificate shall be valid for three years and may be renewed for additional two-year periods if during the Part-Time Provisional certification period preceding the expiration date, the person makes progress toward meeting the requirements of a Five-Year Certificate by completing two semester credits or equivalent approved district in-service activities and furnishing evidence of completed activities.

Approval Certification – Indicates additional areas of certification. Applies to all Gateway staff already holding Five-Year, Provisional, or Part-Time Provisional Certificates. The additional certification area or course would be limited to assignments equal to less than one-half of the annual teaching assignment.

Expiration and Renewal of Approval Certificate – The expiration date for the Approval Certificate shall be the same as the expiration date of the instructor’s Five-Year, Provisional, or Part-Time Provisional Certificates.

Part-Time Approval Certificate – Indicates a special, limited status for occupational instructors. Applies to Gateway adjunct occupational instructional staff who teach no more than two program courses per renewal period.

Requirements for Renewal of Part-Time Approval – The initial Part-Time Approval Certificate shall be valid for three years and shall be renewed for additional two-year periods if during the Part-Time Approval certification period preceding the expiration date, the person completes two semester credits to meet one of the certification requirements, or two months of appropriate occupational experience plus 10 hours of approved in-service activities and submits verifying evidence of the activities.

Wisconsin Technical College System (WTCS) Certification Renewal Requirements:

#50 Curriculum or Course Construction

#51 Technical and Adult Education in the WTCS

#52 Teaching Methods

#53 Educational Psychology

#54 Educational Evaluation

#55 Guidance and Counseling

#69 Educational Diversity

II. GENERAL DEFINITIONS

Certification is an effort to assure quality education in the WTCSB system through a program of continuous participation in activities that will contribute to professional growth.

Certification renewal (or re-certification) refers to courses or professional growth activities that must be completed to keep a certification current. Each activity is assigned a credit value, based upon number of hours of attendance. Certification renewal is an ongoing process and credits must be completed every renewal period.

Renewal (or re-certification) period refers to the length of time allowed to complete the required number of credits for certification renewal. All activities must be completed during the given renewal period, which begins on September 1 and ends of August 31. The length of the renewal period varies with the type of certification.

Activities completed during the final summer of a renewal period, beginning no earlier than May 1 of that year, may be applied toward either the period expiring on August 31 or the next renewal period. This is the only allowable carryover.

Professional Growth is any activity of specific relevance to the staff member’s responsibilities in which the participating person gains professionally, either by attendance or participation in that activity, and/or which activity has direct or potential value to Gateway Technical College or the WTCSB system.

III. OBJECTIVES

The objectives of this recertification plan are:

1. To stimulate professional growth of the staff.

2. To enhance the image of the college and district by encouraging staff to further extend their service to the community.

3. To ensure that staff members keep pace with ever-changing concepts, procedures, and practices in education and in their field of

technical specialty.

4. To meet the requirements of Wisconsin Administrative Code TCS 3.

IV. POLICY

The specific renewal requirements of this section of the plan apply to Gateway personnel holding a Five-Year Certificate. Six (6) credits are required to renew a Five-Year Certificate. (Policy I-200)

V. REQUIREMENTS

All individuals holding five-year certificates are required to renew their certification through one or a combination of the following:

▪ Complete six (6) approved semester credits of course work every 5 years, OR

▪ Complete the equivalent of two (2) months of appropriate occupational experience in their area of certification, OR

▪ Complete the equivalent of six (6) credits of professional growth activity that is described under the section "Approved

Certification Renewal Activities."

A. Credit Limits

Credits may be accumulated from any or all categories up to the maximum credit limit established for each category.

B. Time Limits

All activities completed toward Five-Year certification renewal will be credited only in the applicable five-year period recognized for achieving certification renewal. Carryover of credits into a new certification period will be limited to those credits/hours earned after May 1 and before August 31 of the final year in a certification period. These credits/hours may be applied to the next certification period. All renewal documentation must be in the Certification Office no later than August 1st of the expiring year. (If the staff member is enrolled in a summer course in that time period, proof of enrollment will be accepted.)

C. Prior Approval For Renewal Activities

Requests shall be approved prior to participating in the recertification activity, except as listed below. All renewal activities must be related to the 4 objectives of the Five-Year Certification Renewal Plan.

▪ GTC sponsored activities (i.e., inservice, committee work, etc)

▪ WTCS sponsored activities (i.e., state-called meetings, committee work, etc)

▪ GTEA members performing functions on behalf of the Union.

D. Guidelines For Use Of Professional Growth Activities

▪ Professional growth activities are defined as credit equivalents for renewal of the Five-Year Certificate. All professional

activities have been designated a credit value.

▪ Activities considered as part of normal job responsibilities are not to be used as professional growth credits.

▪ Requests must be made in advance of the activity and approved by the District Certification Officer. Failure to obtain prior

approval may result in the activity being denied.

▪ Documentation is required for all activities. Obtaining the documentation is the employee’s responsibility.

▪ Employees may appeal decisions to the District Certification Committee in accordance with the attached appeal procedure.

VI. APPROVED CERTIFICATION RENEWAL ACTIVITIES

i. Academic Coursework

Completion of a graduate, undergraduate, associate degree or vocational diploma course in a subject area related to the individual's current role is acceptable as an approved recertification activity on a credit-for- credit basis. Courses are not required to be part of a structured program leading to the awarding of a degree to be acceptable. Evidence of auditing a course is acceptable for credit equal to one-half the number of course credits. This does not apply to continuing education courses.

Maximum # of credits for this category: Six (6) credits, auditing is limited to three (3) credits

Required Documentation: Official transcript

ii. Continuing Education

Completion of a manufacturer's school or adult continuing education course in a subject area related to the individual's current role is acceptable as a recertification activity. Forty (40) hours of continuing education equals one (1) credit.

▪ CEU = Continuing Education Unit

▪ CEC = Continuing Education Credit

▪ 1 CEU=10 hours of effort

▪ 4 CEUs = 1 CEC

▪ 1 CEC=1 credit

Maximum # of credits for this category: Six (6) credits (240 hours)

Required Documentation: Certificate of completion

iii. Work Experience

Two (2) months of paid appropriate occupational experience that updates or increases skills or knowledge applicable to the instructor's job will qualify as a recertification activity. Occupational experience will be equated to credits using the following formula. Hours of occupational experience must be documented on a non-teaching occupational experience form.

▪ 1 Credit = 55 Hours 4 Credits = 220 Hours

▪ 2 Credits = 110 Hours 5 Credits = 275 Hours

▪ 3 Credits = 165 Hours 6 Credits = 330 Hours

Maximum # of credits for this category: Six (6) credits (240 hours)

Required Documentation: Verification of Non-teaching Occupational Experience form (see Forms)

iv. Approved Professional Growth Activities

Approved professional growth activities may include, but are not limited to the following:

A. Workshop, Conference, Seminar, Webinar

Attendance at a workshop, conference, or seminar where the subject is related to the district's purpose and/or the individual's current role or performance in the district is an acceptable renewal activity.

Maximum # of credits for this category: Six (6) credits (240 hours) each recertification period

Required Documentation: completed Professional Growth Record form (see Forms)

B. Teaching

Teaching a graduate, undergraduate, associate degree, or vocational-diploma course will be an accepted recertification activity for non-instructional personnel, based upon the same number of credits as earned by the student.

Teaching a graduate or junior/senior level undergraduate course will be recognized as an accepted recertification activity for instructional personnel, based upon the same number of credits as earned by the student. Information from the college including course number, course title, number of credits, and academic level must be provided to the Certification Office.

Teaching a certification course or equivalent in-service activity will be recognized as an accepted recertification activity for non-instructional and instructional personnel, based upon the same number of credits or credit equivalents as earned by the student. The experience of teaching at the indicated levels is the basis for recognition of the activity for recertification purposes.

Maximum # of credits for this category: Three (3) credits each recertification period

Required Documentation: completed Professional Growth Record form with course information from college (see Forms)

C. Professional Service

Performance as a chairperson, officer, committee chairperson, or planning committee member of a recognized national, state, regional, or local professional work-related association or committee is an approved recertification activity. Service on in-house committees designated as approved for recertification by the District Certification Committee may be accepted.

Maximum # of credits for this category: Two (2) credits (80 hours) each recertification period

Required Documentation: completed Professional Growth Record form (see Forms)

D. Professional Speaking

Responsibility for making a formal presentation at a professional conference, workshop, or seminar may be recognized as an approved recertification activity with both the presentation and preparation time used to calculate professional growth. Credit awarded in this category is based on preparation and presentation time. Documentation of preparation, attendance and presentation time is required.

Maximum # of credits for this category: Two (2) credits (80 hours) each recertification period

Required Documentation: completed Professional Growth Record form with documentation of preparation, attendance and presentation time (see Forms)

E. Cross-Training

A formal cross-training effort or program in which a staff member interns, substitutes, or otherwise formally receives training or experience in a role other than his/her primary assignment within the Gateway District or the Wisconsin Technical College System is recognized for recertification credit. Appropriate cross-training work experience that updates or increases skills or knowledge applicable to the employee's job may be recognized for professional growth credit. Each credit must demonstrate at least 40 hours of work. A cross-training program must serve the district's purposes and/or the individual's current role with the district.

Maximum # of credits for this category: Two (2) credits (80 hours) each recertification period

Required Documentation: completed Professional Growth Record form (see Forms)

F. Alternate Assignment

An alternate job assignment that is not related to the job or primary job assignment and/or which contributes to the professional growth of the staff member, such as an instructor who performs management-related responsibilities or a manager who performs in a faculty role may be recognized as an approved recertification activity. Lead and Chair duties cannot be used for recertification.

Maximum # of credits for this category: Two (2) credits (80 hours) each recertification period

Required Documentation: completed Professional Growth Record form (see Forms)

G. Literary Accomplishment

Researching, writing, and having published occupationally oriented materials related to the staff member's role or to the purposes of education in general may be approved for professional growth credit.

The completion of a textbook may be considered for additional professional growth credits based on one credit for every fifty (50) pages up to a maximum of six (6) credits (300 pages). A manuscript must be submitted for review.

The revision of a textbook may be considered for additional professional growth credits up to a maximum of three (3) credits. One-half (1/2) credit for every fifty (50) pages. A revised manuscript must be submitted for review.

Maximum # of credits for this category: 6 credits (300 pages) or 3 credits (150 pages) each recertification period

Required Documentation: Manuscript or revised manuscript for revision

H. Leadership Role

A leadership role as an officer, member, or part of the governing body of a professional (non-work-related) or community service (non-sectarian, non-political) organization may be approved as a professional growth activity. Such leadership activity is considered because of its personal development potential and its public relations impact on the school, the community, and the individual.

Maximum # of credits for this category: Two (2) credits (80 hours) each recertification period

Required Documentation: completed Professional Growth Record form (see Forms)

I. Educational Innovation

The development of unique and innovative methods in teaching and learning may be recognized as an approved recertification activity. A proposal describing the project, objectives, and final product must be submitted for approval, and the project must have an outcome that can be implemented.

Maximum # of credits for this category: Three (3) credits (120 hours) each recertification period

Required Documentation: completed Professional Growth Record form (see Forms)

J. Consultant/Evaluator

Non-paid service as a consultant/evaluator in the public or private sector may be recognized as an approved recertification activity. The activity must culminate in a written report provided to the client.

Maximum # of credits for this category: Two (2) credits (80 hours) each recertification period

Required Documentation: completed Professional Growth Record form (see Forms)

K. Research and Development

Conducting community studies, needs surveys, or evaluation studies not currently being conducted by the research department may be recognized as an approved recertification activity. A written proposal detailing the project, objectives, and desired outcome must be submitted for approval. The project must be conducted in collaboration with an established research department and must culminate in a written report and dissemination of information throughout the district.

Maximum # of credits for this category: Three (3) credits (120 hours) each recertification period

Required Documentation: completed Professional Growth Record form (see Forms)

L. Technical Updating

Participation in the Educational/Industrial Exchange Program or any formally approved program designed to enhance technical expertise in the individual's area of assignment through a variety of on-the-job experiences is an approved recertification activity.

Maximum # of credits for this category: Three (3) credits (120 hours) each recertification period

Required Documentation: completed Professional Growth Record form (see Forms)

M. National and International Study Tours

Participation in an organized national or international study tour through an institution of higher learning which grants credit for the activity is recognized for recertification credit. Appropriate activity which updates or increases skills or knowledge applicable to the employee’s job may be recognized for professional growth credit. Travel time is not included. Credit from the granting institution shall take precedence over hours of participation.

Maximum # of credits for this category: Two (2) credits (80 hours) each recertification period

Required Documentation: completed Professional Growth Record form or Official transcript(see Forms)

N. Mentor/Professional Development Team Member

Service as a mentor in Gateway's formalized mentoring program, or service as supervisor of a formalized practicum experience will be recognized as an approved recertification activity.

Maximum # of credits for this category: Two (2) credits (80 hours) each recertification period

Required Documentation: completed Professional Growth Record form (see Forms)

O. Community Service

Community service activities (non-sectarian, non-political), including volunteer work, may be accepted as a professional growth activity. Such service is considered because of its personal development potential and its public relations impact on the school, the community, and the individual.

Maximum # of credits for this category: One (1) credit (40 hours) each recertification period

Required Documentation: completed Professional Growth Record form (see Forms)

P. Occupational Certification/Licensure

Successful completion of exams to attain occupational certification or licensure which is directly related to the individual=s current role and/or the district=s purpose may be accepted as a professional growth activity. Six (6) hours of preparation time will be accepted for each required hour of testing.

Maximum # of credits for this category: Two (2) credits (80 hours) each recertification period

Required Documentation: completed Professional Growth Record form (see Forms)

Q. Grant Writing

Pre-approved grant writing proposals may be recognized as an approved recertification activity. The amount of time devoted to preparation, research, and/or writing may be evaluated.

Maximum # of credits for this category: Two (2) credits (80 hours) each recertification period

Required Documentation: completed Professional Growth Record form (see Forms)

R. Service Learning

Participation in an organized service learning activity through an institution of higher learning which grants credit for the activity is recognized for recertification credit. Appropriate activity which updates or increases skills or knowledge applicable to the employee’s job may be recognized for professional growth credit. Travel time is not included. Credit from the granting institution shall take precedence over hours of participation.

Maximum # of credits for this category: Two (2) credits (80 hours) each recertification period

Required Documentation: completed Professional Growth Record form (see Forms)

S. Miscellaneous

The Certification Officer may consider activities not covered in the previous categories. An activity is worthy of consideration if it is beyond the employee’s normal contract obligations and if it involves practical experience that will enhance the employee’s understanding of the field/area in which they are working. The individual must submit a written request to their Dean for pre-approval.

Maximum # of credits for this category: Two (2) credits (80 hours) each recertification period

Required Documentation: completed Professional Growth Record form (see Forms)

VII.

CERTIFICATION APPEALS PROCESS

A. Purpose:

The purpose of the certification appeal process is to promote voluntary settlement of any disputes concerning certification or certification renewal at the local district level. Staff is responsible for ensuring that information submitted with their request for approval of certification activities is complete. The appeal must be filed within 45 calendar days of the action or inaction, which serves as the basis of the appeal. Appeals are covered under provisions of the code contained in TCS 3.16. Decisions may be appealed at the District level or directly to the State Board.

B. Procedure:

Any person aggrieved by a decision of the District Certification Officer may appeal that decision according to the following guidelines:

Request for Appeal to the District Certification Officer

The requestor sends to the district certification officer a written statement supporting the professional value of the activity.

The district certification officer, within fifteen working days after the receipt of the appeal, makes a second decision and returns

the decision to the requestor.

Request for Appeal to the District Certification Committee

1. The requestor sends to the chairperson of the District Certification Committee or Certification Officer, a request to convene the

District Certification Committee to review the request.

2. The District Certification Committee chairperson or Certification Officer acknowledges receipt of the request within 15 days

And convenes a meeting of the District Certification Committee.

3. The District Certification Committee meets and makes a decision within 45 days of receipt of the request.

4. Chairperson of the District Certification Committee informs the requestor of the decision.

5. Chairperson of the District Certification Committee informs the requestor of the right to appeal the decision to the State

Certification Committee.

Request for Appeal to the State Certification Committee

If an activity for recertification credit is disapproved by the District Certification Committee, the decision may be appealed to the State Certification Committee. The procedure is as follows:

The staff member seeking recertification (requestor) shall send a written request to the State Certification Committee, in care of

the State Certification Officer, asking that the decision be reviewed.

Upon receipt of the request, the State Certification Officer will solicit written statements from all involved parties. The written

material will include only information that has been shared with all parties.

The State Certification Committee will consider the appeal at the next scheduled meeting after all written material has been

submitted.

FORMS

GATEWAY TECHNICAL COLLEGE

FIVE-YEAR CERTIFICATION

ANNUAL PROFESSIONAL GROWTH RECORD

Name: Certification Expiration Date:

Colleague ID #:

| | | |

|PROFESSIONAL GROWTH ACTIVITIES |H = Leadership Role (2 Cr. Max) |O = Community Service (1 Cr. Max) |

|A = Workshop,Conference,Seminar,Webinar (6 Cr. Max) |I = Educational Innovation (3 Cr. Max) |P = Occupational Certification/Licensure (2 Cr. Max) |

|B = Teaching (3 Cr. Max) |J = Consultant/Evaluator (2 Cr. Max) |Q - Grant Writing (2 Cr. Max) |

|C = Professional Service (2 Cr. Max) |K = Research and Development (3 Cr. Max) |R – Service Learning (2 Cr. Max) |

|D = Professional Speaking (2 Cr. Max) |L = Technical Updating (3 Cr. Max) |S – Miscellaneous (2 Cr. Max) |

|E = Cross-Training (2 Cr. Max) |M = Professional Exchange Program (3 Cr. Max) | |

|F = Alternate Assignment (2 Cr. Max) |N = Mentor/Professional Development Team | |

|G = Literary Accomplishment (2-6 Cr. Max) |Member (2 Cr. Max) | |

Group activities by category; indicate category letter and title in space provided.

Category ______________________________

| | |

| | |

|Beg/End Date(s) (required) | |

|Email (Required for Adjunct Faculty Only)______________________________________________________________________________ |

|VI. APPROVED CERTIFICATION RENEWAL ACTIVITIES (Check one per activity; refer to the current 5YR Renewal Plan) |

| |

|i. ( Academic Coursework - Required documentation: Official Transcript* |

|ii. ( Continuing Education - Required documentation: Certificate of Completion |

|iii. ( Work Experience - Required documentation: Non-teaching Occupational Experience form |

|iv. Professional Growth Activities | |

|Requires appropriate documentation | |

| | |

|( A. Workshop, Conference, Seminar (6 Cr. Max.) | |

|( B. Teaching (3 Cr. Max.) |( K. Research and Development (3 Cr. Max.) |

|( C. Professional Service (2 Cr. Max.) |( L. Technical Updating (3 Cr. Max.) |

|( D. Professional Speaking (2 Cr. Max.) |( M. Professional Exchange Program (3 Cr. Max.) |

|( E. Cross-Training (2 Cr. Max.) |( N. Mentor/Professional Development Team Member (2 Cr. Max.) |

|( F. Alternate Assignment (2 Cr. Max.) |( O. Community Service (1 Cr. Max.) |

|( G. Literary Accomplishment (6 Cr. Max; revision 3 Cr. Max) |( P. Occupational Certification/Licensure (2 Cr. Max.) |

|( H. Leadership Role (2 Cr. Max.) |( Q. Grant Writing (2 cr. Max.) |

|( I. Educational Innovation (3 Cr. Max.) |( R. Service Learning (2 Cr. Max.) |

|( J. Consultant / Evaluator (2 Cr. Max.) |( S. Miscellaneous (2 Cr. Max.) |

| | |

|Describe Activity (For academic coursework, include name of college, course description and syllabus if available)____________________ |

|________________________________________________________________________________________________________________ |

|________________________________________________________________________________________________________________ |

|________________________________________________________________________________________________________________ |

|________________________________________________________________________________________________________________ |

|Start Date & End Date of Activity:_____________________________________ |Indicate Number of Credits _____ or CEU’s ______ or Hours ______ |

| | |

|NOTE: Upon completion, required documentation must be submitted to the Certification Office. |

| |

|( APPROVED ( NOT APPROVED+ ( APPROVED ( NOT APPROVED+ |

| | |

|___________________________________________ |_______________________________________________ |

|Supervisor |Certification Officer |

|Date____________________________ |Date____________________________ |

|Comments___________________________________________ |Comments_________________________________________________________ |

|____________________________________________________ |__________________________________________________________________ |

|____________________________________________________ |__________________________________________________________________ |

ROUTING: Instructor, Dean, Certification Office +See Five-Year Certification Renewal Plan for appeal process.

AN EQUAL OPPORTUNITY / ACCESS EDUCATOR / EMPLOYER HR – 2/12

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VERIFICATION OF NON-TEACHING EMPLOYMENT

The Wisconsin Technical College System Board requires verification of employment to grant certification. Paid occupational experience related to the area being taught is required for occupational instructors. Paid non-teaching experience is required for academic instructors.

APPLICANT/EMPLOYEE: Please complete the following authorization section and send this form to your current or former employer.

Name of Applicant: _____________________________________________

Address: _____________________________________________

_____________________________________________

Social Security No: _____________________________________________

I hereby authorize:

Name of employer: _____________________________________________

Address: _____________________________________________

_____________________________________________

to furnish Gateway Technical College with the information requested below.

Signature: Date:

EMPLOYMENT RECORD (To be completed by employer and returned to Gateway Technical College.)

The above-named person was employed at this company from: ________________ to: __________________

______ Full-time/approximately ________ total hours

______ Part-time/approximately ________ total hours

2. What was the number of hours of employment per week? ________________ (filling in this field is mandatory)

3. Job Title/Classification:

(Please attach a job description if available)

Use reverse side for additional information/comments

Your Signature: Date:

Your Title:

Phone Number:

EMPLOYER: Please fax the completed form to Mary Halberstadt, District Certification Officer, 262-564-2838

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