Performance Learning Systems Application

Required Materials

  • Photocopy of Teaching License (Current or Expired)
  • If currently employed in the teaching profession, submit the employee verification form.

Fax materials to 219.464.5381 or email to Sandra.Chermak@valpo.edu

I. Personal Information
Last Name
First Name
Middle Name
Former Name
Date of Birth
Social Security Number
Gender:
 
Home Address
Address
City
State
Postal Code
 
Contact Information
Home Phone
Cell Phone
Email
If you do not have an email address, please type "None".
 

II. Enrollment Plans
Term Attending: Fall     Spring     Summer     Year:

III. Employment & Professional Background
Name of School or Employer:
Job Title:
Address:
Work Phone #:
May we contact you at work?
Will you receive employer reimbursement?

IV. Educational Background
Have you taken coursework at Valparaiso University? Yes     No
    (If yes: Undergraduate     Graduate)
 
College/University Degree Earned (BS/BA/Masters Degree) or CE Credits:
BS    BA    Masters    CE Credits    Other   

By entering your full name below you are signing this electronic application form.
"I submit this application as a true and complete statement of facts for your consideration."
Applicant Signature:
Application Date: