Application
1. Your name ___________________________ Department ______________________
2. Your email ___________________________ Phone number____________________
3. Courses you are scheduled to teach next year
Fall 2014:
Spring 2015:
4. Which one semester do you prefer to have the 3-unit course reassigned time?
____ Fall 2014
OR
____ Spring 2015
5. Please write a statement of strong interest and commitment to fully participating in the
Five Gears faculty learning community. Your statement should not exceed 500 words,
and it should be attached to this application.
6. Your signature _____________________________________________
Your signature confirms your availability to meet for two (2) hours at all ten (10)
of the FLC meeting times listed in this Call to Participate, barring an emergency.
7. Your department chair’s signature (this must be the chair of your Five Gears FLC target
course)
__________________________________________________________
The chair’s signature confirms that to the best of her/his knowledge, the applicant will
be teaching the courses listed above, and that the requested reassigned time will not
adversely impact the department.
8. Submission requirements:
 Hand deliver one copy of your application (with statement attached) to Kelly
Kroeker in CIELO (x6535, Sierra Hall, 4th floor “roof”) by 12:00 noon on
Monday, May 12, 2014.
 Email an electronic copy to Cynthia Desrochers at cdesrochers@csun.edu.
 Keep a copy for yourself.