Avatar New User Setup Request

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Avatar New User Setup Request Powered By Docstoc
					                                 Avatar New User Setup Request
                                           Please complete and return to:
                                         Professional Development Academy
                                                    621 Bluff Rd
                                                Columbia, SC 29201
                                                 Fax: (803) 400-1686
First Name *   __________________________
Last Name *    __________________________
     Email *   __________________________
      SSN *    __________________________
  Employee     ___________________
      Type
               Select One from the Following:
                                                                        Guidance Counselor
                      AAP Teachers                                     Media Specialist
                      Administrator                                    Nurse
                      Area Specialist                                  Occupational/Physical Therapist
                      Area Superintendent                              Paraprofessional
                      Assistant Principal                              Principal
                      Athletics Coach                                  Psychologist
                      Band Asst. Director                              Reading Specialist
                      Band Director                                    ROTC
                      Bookkeeper                                       Special Services
                      Child Nutrition                                  Speech Pathologist
                      Classified                                       Student Teacher
                      Consultant                                       Substitute
                      Coordinator                                      Superintendent
                      Curriculum Resource Teacher                      Support Personnel
                      Deputy Superintendent                            Teacher
                      Diagnostician                                    Teacher/Coach
                      Director                                         Technology Educator
                      Executive Director                               Trainer
                      Facility Services                                Transportation
                                                                        Database Specialists
Employee ID
           *   __________________________
      Home
 Address 1 *   __________________________
      Home
  Address 2    __________________________
      City *   __________________________
     State *   __________________________
 ZIP Code *    __________________________
 Work Site *   ___________________
               Select One from the Following or write “Out of District”:
                      PDA               280                 372                  495            620      722
                      110               295                 375                  510            630      723
                      114               297                 378                  515            634      740
                      120               303                 381                  520            640      743
                      130               306                 384                  523            650      746
                      132               309                 390                  524            660      750
                      140               310                 392                  525            669      760
                      150               312                 393                  530            675      765
                      160               321                 394                  532            680      770
                      170               330                 396                  540            682      775
                      172               333                 397                  547            685      780



                              * Indicates required field for form to be processed.
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                      210              336                 398                  550      695      812
                      220              339                 399                  555      710      840
                      230              342                 430                  560      712      850
                      240              351                 445                  570      713      852
                      250              354                 446                  580      714      858
                      260              357                 460                  582      715      905
                      270              366                 480                  583      716      913
                                        369                 490                  586      721
  Certificate
    Number      __________________________
  Certificate
      Area 1    __________________________
  Certificate
      Area 2    __________________________
  Certificate
      Area 3    __________________________
  Certificate
      Area 4    __________________________
  Certificate
      Area 5    __________________________
 Technology
Competency
      Yearly    __________________________
   Progress
 Technology
 Proficiency    _________ (MM/DD/YYYY)
        Date
Home Phone      (___) ___ - _____ (ext _____)
Work Phone      (___) ___ - _____ (ext _____)
  Credential
   Start Date   _________ (MM/DD/YYYY)
  Credential
    End Date    _________ (MM/DD/YYYY)
RichlandOne
 Username *     __________________________




                             * Indicates required field for form to be processed.
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