Invoice Request Form - DOC - DOC

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Invoice Request Form - DOC - DOC Powered By Docstoc
					                                                                                                         Request for a CRLA - ITTPC Invoice
                                                                                                        Please Email Your Completed Request Form to:
                                                                                                                  ITTPC.Updates@crla.net.
                                                                                                       We will send you the invoice ASAP. The CRLA-ITTPC Team.
Section 1: Program Details Information:
1. Level(s) Requested: Mark an “X” for EACH certification level you are either re-applying for, or, you are applying to add now:
     Re-applying for: __ Level I / Certified Program                      __ Level II / Advanced Certified Program                   __ Level III / Master Certified Program
     Applying to add: __ Level I / Certified Program                      __ Level II / Advanced Certified Program                   __ Level III / Master Certified Program
2. Program Details: (NOTE: For the certificate, in #2 & #5, be sure to list EACH Program & EACH Campus involved in your tutor training processes.)
     [FYI: When contacting CRLA-ITTPC, ALWAYS include your Country_State_Inst Name-Appl City-Campus(es) - Program Name – ID # (if known) - Levels
        to insure an accurate reply = example: USA_AZ_Sampleville State U- Zville - Zville Campus - Learning Center - ITTPC-USA-AZ-0001 - L123]
     Institution Name:
     Official Name of This Tutor Training Program:
     Names of each Program & Campus to be listed on this certificate:
       Multiple programs &/or campuses can be supported under the same certificate, if they are coordinated and have the same tutor selection, training topics, tracking, and evaluations.
       [i.e.: Zville (Main) Campus & North Campus & South Campus & Eastside Campus & Westwood Center; & Student Success Program @ Metro Campus - Writing Center]

     ITTPC Program ID# (if known): ITTPC- ___ - __ - _ _ _ _ [format: ITTPC - Country - State - 4 digit ID#. {ex: ITTPC-USA-AZ-0001}]
       Find your ID # for: Currently Certified Tutor Training Programs, see: http://www.crla.net/ittpc/current_certifications.htm , & click on ‘downloads document’.
        - OR - for Apps already in process, see: http://www.crla.net/ittpc/AppStatus.htm , & locate your full program ID #. - OR - App. for new program = No ID# yet!

     Program’s Webpage URL Address Link:
     Program’s Street Mailing Address:
     City, State/Province, Country, Postal/Zip Code (if used, include Zip+ numbers):
3. Your Permission for ITTPC to use this appl. packet as a “Sample Appl.” or a “Model Program”:                                         __ YES         __ NO, I prefer not.
       Occasionally, applications are selected to post on the ITTPC website as either a “Sample Application” or a “Model Program” for colleagues to see
       ‘how it may be done’, & to share ideas with colleagues. A “YES” reply gives ITTPC permission to post the full contents of YOUR application packet on our website.

4. Administrative/Supervisory Designation for This Specific Tutor Training Program: [Mark an “X” for option A or B listed below.]
     The name of each certified program &/or campus listed on the appl. will be listed on their Program Certificate (.pdf) emailed to your ‘primary contact’.
      __ A) Primary-Program Unit only [One Program on One Campus], listed under one certificate,
                where that one program is directly responsible for all of these tutor training program functions:
                      a) Tutor Selection; b) Tutor Training Topics; c) Tutor Experience Tracking; d) Tutor Evaluations, &, e) Tutor Certification.
                The ‘Primary-Program Unit Fee’ per level requested in this application applies. [ See the ITTPC website: “Application Fees”.]
      __ B) Primary-Program Unit plus Additional-Units [for Multiple Campuses &/or Multiple Programs], listed under one certificate,
                where each of two or more campuses &/or programs coordinate resources and offerings to provide the
                same CRLA-ITTPC approved minimum core policies & processes for any of these tutor training program functions:
                      a) Tutor Selection; b) Tutor Training Topics; c) Tutor Experience Tracking; d) Tutor Evaluations, &, e) Tutor Certification.
                The ‘Primary-Program Unit Fee’ per level requested in this application applies,
                plus an added $50 per level charge for each added campus &/or program on this appl. [ See the ITTPC website: “Application Fees”.]
5. Program Contact(s) for This Primary-Program Unit’s Application:                                       [‘Sample tables’ below show examples for both designation A & B.]
      Your program’s ‘Primary Contact’ overseas and is responsible for your whole tutor training program. Each ‘contact’ you list in the table below
         is a person who is responsible for one or more aspects of your program’s tutor training certification requirements, which include the following:
                  a) Tutor Selection, b) Tutor Training Topics, c) Tutor Experience Tracking, d) Tutor Evaluations, or, e) Tutor Certification.
      In the table below, include the following information:
           the name of each program and each campus involved with this primary-program unit’s tutor training functions listed above.
                If more than 1 program is also involved in your training program, list each added program & their participating campus(es) as well.
           the name, title, email address, & contact phone # of this primary-program unit’s ‘Primary Contact’
                If applying for more than 1 campus &/or added programs, list this info for at least one contact person for each campus &/or program.
      If one person supervises multiple programs/campuses, list that name for that entry. [Only permanent employees, no grad assistants, temp employees, etc.]

                Each ‘contact’ listed below should also submit a signed “Application Agreement” (appl: Section 8) to the “Primary Contact” to keep in their files.
                               The signed application agreement indicates that they agree they will continue to follow the CRLA-ITTPC requirements
                                           for each level of tutor training at their program’s campus, just as approved for this certification.

        Each Program Name             Related Campus Name
        [List primary-program unit       [List primary-program                Primary Contact & Other Contact Names:
                                                                                                                                                 Email address                      Phone #
               first, then any           unit campus first, then               [Dr/Mr/Mrs./Ms] Name, & Position Title
       additional program name(s)]       any other campus(es)]
  [sample: Learning Center]          [sample: Zville Campus]           [sample: Dr.Rick Sheets, Learning Center Director]               [sample: rick.sheets@xyzu.edu]       [623-240-0572]
                                                                       (Primary Contact):
                                                                       (other contacts):




                                                                                  [To add a row to the table, place the cursor in the last cell of the table, and press the ‘tab’ key.]
      NEED MORE SPACE for NAMES? You can delete sample tables A & B below if you need more space for YOUR program’s information in the table above.
SAMPLE TABLES for Options A & B:
 A. Primary-Program Unit [One Program on One Campus], listed under one certificate, where that one program is directly responsible for all of these tutor training program functions:
        a) Tutor Selection; b) Tutor Training; c) Tutor Experience Tracking; d) Tutor Evaluations, &, e) Tutor Certification. [Primary Fees apply.]

      Each Primary-Program Unit            Related Campus Name                       Primary Contact & Other Contact Names:                       Email address                      Phone #
              Name Only                  [List campus(es) under this                 [Dr/Mr/Mrs./Ms] Name, & Position Title
                                            primary-program unit]
  Learning Success Center            Zville (Main) Campus                    Dr. Sue Johnson, Director                                  sue.johnson@xyzu.edu                 623-240-0572
                                     (use campus or city name)
  Learning Success Center            Zville (Main) Campus                    Mr. Art Ramirez, Coordinator                               art.ramirez@xyzu.edu                 623-240-0573
                                     (use campus or city name)

 B.     Additional-Units [Multiple Campuses and/or Multiple Programs], listed under one certificate,
          where each of two or more campuses &/or programs coordinate resources and offerings to provide the same CRLA-ITTPC approved minimum core policies & processes for any of these tutor
          training program functions: a) Tutor Selection; b) Tutor Training; c) Tutor Experience Tracking; d) Tutor Evaluations, &, e) Tutor Certification.
          [NOTE: Certifying additional campuses &/or programs under one certificate requires additional fees. See ITTPC Website Fee Schedule: ‘Auxiliary-unit’.]
        Each Program Name                     Corresponding                    Primary Contact & Other Contact Names:                     Email address           Phone #
        (** = added program)                  Campus Name                       [Dr/Mr/Mrs./Ms] Name, & Position Title
   Learning Assistance Center   Zville North Campus Science Center            Dr. Ruth Doe, Director                             rdoe@xyzu.edu            623-240-0572   x5545
   Learning Assistance Center   Zville South Campus Science Center            Dr. Marvin Helper, Assistant Director              mhelper@xyzu.edu         623-240-0572   x5546
   Learning Assistance Center   Zville Eastside Campus Math Lab               Mr. Art Ramirez, Coordinator                       aramirez@xyzu.edu        623-240-0572   x5551
   Learning Assistance Center   Zville Westwood Campus Math Lab               Dr. Jerri Smith, Coordinator                       jsmith@xyzu.edu          623-240-0573   x7110
   **Student Success Program    Zville Metro Campus Writing Center            Dr. David Roberts, Program Director                droberts@xyzu.edu        623-240-0575   x7220
                                                                              Ms. Nancy Teacher, Coordinator                     nteacher@xyzu.edu        623-240-0575   x7225
Rev. 6/10/2012 BJS              Thank you for completing this update form. It will help insure accurate information in your file. The ITTPC Coordinator

				
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