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

I. Personal Information
Last Name
First Name
Middle Name
Former Name
Date of Birth
Social Security Number
Home Address
Postal Code
Contact Information
Home Phone
Cell Phone
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:
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: