Instructor Application
Pages 1/3
Extended Learning, California State University San Marcos, San Marcos, CA 92096-0001 760-750-4020
Thank you for your interest in teaching for California State University San Marcos, Extended Learning. Please complete
the following course proposal, save to your computer and Email to: cscavone@csusm.edu, Fax: (760) 750-3138 or
Mail: Cal State San Marcos Extended Learning, Attn: Cathy Scavone, San Marcos CA 92096-0001. This form
should not be handwritten.
CONTACT INFORMATION:
First Name:
Last Name:
HOME INFORMATION:
Address:
Home Phone: (_____)
City:
State:
Zip:
Cell Phone: (_____)______________ Fax: (____)___________
Email:
WORK INFORMATION:
Company:
Title:
Address:
City:
State:
Zip:
Phone: (____)_______________ Fax: (____)________________ Email:
PROFESSIONAL REFERENCES:
Please provide three professional references to support your professional and teaching experience.
1. Reference Name:
Title:
Relationship:
Company:
Address:
City:
2. Reference Name:
ZIP:
State:
ZIP: ________
State:
ZIP:
Title:
Relationship:
Company:
Address:
City:
3. Reference Name:
State:
Title:
Relationship:
Company:
Address:
City:
I am authorizing CSU San Marcos to request information about my professional teaching or work related experience. I am also
including a copy of my most current resume/CV that details my professional experience, teaching history, professional certifications
and affiliations, and bibliography of published works. SEE ATTACHED RESUME/CV.
Instructor Signature:
Date:
Instructor Application
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Extended Learning, California State University San Marcos, San Marcos, CA 92096-0001 760-750-4020
Name:_________________________________
Please attach current CV and/or Resume
Education/Certifications
Highest Level of Education:  Ph.D.  Masters  Bachelors  Associate  NA
Field of Study:
School Name:
Year:
Please list all certifications that you hold (association/certification year)
_____________________________________________________________________________________
Awards/Publications/Associations
Please list all professional awards that you have received (please specify)
_____________________________________________________________________________________
Have you authored any publications/articles? If yes, please provide publication/article title and publish date.
____________________________________________________________________________________
____________________________________________________________________________________
What industry, professional or community associations are you active in? In what capacity?
(i.e. Board member/year)
________________________________________________________________________________________
________________________________________________________________________________________
Teaching Experience
Do you currently teach at a College/University?  Yes  No
If yes, please indicate:
College/University/Department:
Course Topics/Year:
__________________
College/University/Department:
Course Topics/Year:
__________________
If no, please indicate other teaching experience:
____________________________________________________________________________________
____________________________________________________________________________________
Are you bi-lingual?  Yes  No Please specify languages ____________________________________
Are you available to teach (check all that apply):  Weekdays  Weekends  Daytime  Evening
Instructor Application
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Extended Learning, California State University San Marcos, San Marcos, CA 92096-0001 760-750-4020
Name:_________________________________
Are you available to teach (check all that apply)
 San Marcos Campus
 Temecula Campus
In addition to training, are you also available for consulting work?  Yes  No If yes, in what areas?
________________________________________________________________________________________
________________________________________________________________________________________
What industries do you have primary experience working with?
______________________________________________________________________________________
______________________________________________________________________________________
Indicate which employee level you feel you are most effective working with? Please rank order with 1 being
the most effective.
Executive
Middle Management
Supervisors/Front Line Management
All levels
Additional information you would like to add:
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
Thank you for taking the time to complete this
application. The information you provided us will
ensure that we are able to make the best match of an
instructor’s background and expertise to our client’s
specific needs. Please return this application by either
selecting “Submit” or download and Email:
cscavone@csusm.edu, Fax: (760) 750-3138 or Mail:
Cal State San Marcos Extended Learning, Attn:
Cathy Scavone, San Marcos CA 92096-0001