INSTRUCTOR INFORMATION

Name:

SSN: Phone: (home)

Work:

Fax:

E:mail:

Address:

SUBJECT INFORMATION

Name/Title of Proposed Class:

Please give a short description of your subject:

Please provide credentials applicable to subject matter.

SCHEDULING NEEDS

Campus to offer class (Wilburton, Idabel, McAlester) Select A Campus Eastern Campus McAlester Campus Idabel Campus

Length of class time: (approx.) Number of times class to meet:

Time of Day:

Special equipment needs: (example - piano, computer, lectern)

Other Information:

Please fill out one form for each class or course you wish to offer. Thank you for your prompt reply.