teaching certificate no by 2du89zN

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                                                         HEALTH SCIENCE EDUCATION
                                                    FACULTY VITA - SCHOOL YEAR 2004-2005


PRINT:      BLACK INK

NAME                                                                                     SOCIAL SECURITY NO.

HOME ADDRESS

CITY                                                                                               ZIP

PHONE NUMBER:           HOME                                                             WORK

PRESENT TEACHING POSITION

R.N. LICENSE NO.                                        Exp. Date

TEACHING CERTIFICATE NO.                                                     TYPE

EXP. DATE               CERTIFICATION AREAS

EMPLOYMENT DATES: FULL-TIME                                         PART -TIME

CPR INSTRUCTOR CERTIFICATION:                  BLS: EXP. DATE                                                  INSTR: EXP. DATE

OTHER PROFESSIONAL CERTIFICATIONS/NUMBER/EXP. DATE:




EDUCATION (Highest to Lowest)
         NAME OF SCHOOL                        DEGREE/DIPLOMA                    MAJOR SPECIALTY    DATE COMPLETED




ADDITIONAL COURSE WORK (COMPLETED 2002-2003 SCHOOL YEAR)




PROFESSIONAL EMPLOYMENT (MOST RECENT FIRST)
                                                                                                            TOTAL YRS. CLINICAL EXP.
 INSTITUTION                   CLINICAL AREA           INCLUSIVE DATES                (CALCULATE ON 1900 HR. = 1 YR)




LIST PROFESSIONAL ORGANIZATION MEMBERSHIP




TEACHING EMPLOYMENT
                                                                                                    TOTAL YRS. TEACHING EXP.
            INSTITUTION                                 PROGRAM                           (CALCULATE ON 1000 HR. = 1 YR)




ADDITIONAL EXPERIENCE OUTSIDE SCHOOL SYSTEM (I.E. HOSP. INSERVICE, CEU, ADJUNCT, COMMUNITY ACTIVITES)




SIGNATURE                                                                                Date




NOTE: SHOULD MORE SPACE BE NECESSARY, USE BACK SIDE OF FORM. Attach resume if available.

Revised 06/04

								
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