High School Relations and
Community Outreach
80 Fort Brown ▪ Brownsville, Texas 78520 ▪ www.tsc.edu
Dual Enrollment School
Instructor Credentialing Request Form
Date: ______________
Contact Information:
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H.S. Instructor
TSC Instructor
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Name: __________________________________________________________
DOB: ____________________
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School: _________________________________________________________
Email: ____________________
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Address: ________________________________________________________
Phone #: __________________
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Proposed Year/ Semester: _________FALL_________SPRING
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Proposed Courses:
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ISD Course Title
TSC Course Title
# of Sections
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Academic or Technical Course
Instructor Qualifications: Instructors
associate degree courses designed for transfer
r teaching general education courses or teaching
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to a baccalaureate degree require a Master’s degree in the teaching discipline or a Master’s degree with a minimum of eighteen (18)
s
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graduate semester hours in the teaching discipline,
from an accredited college or university.
In addition, instructors teaching associate
o degree or higher and at least three years of
degree courses not designed for transfer toothe baccalaureate degree require an Associate’s
documented direct or related work experience
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Name of School
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e Major & Degree
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Instructor Name (please print)
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School Administration Approval/nTitle
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TEXAS SOUTHMOST COLLEGE USE ONLY:
Signatures:
Received By:
 Approved
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Graduate
Hours
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Years of Work Experience in
Field (other than teaching)
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Instructor Signature
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n District Administrator Approval/ Title
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Date:
 Denied
Comments:
Processed By:
Texas Southmost College
High School Relations and Community Outreach
Date:
Revised 09/18/2014
Page 1 of 3
Early College High School
Instructor Education & Experience
Educational History:
What is the highest education level you
have completed?
Name of College, Business, or Trade
School
Major Concentration
Graduation Date
Degree Type
Name of College, Business, or Trade
School
Major Concentration
Graduation Date
Degree Type
Name of College, Business, or Trade
School
Major Concentration
Graduation Date
Degree Type
Name of College, Business, or Trade
School
Major Concentration
Graduation Date
Degree Type
*** (For additional information – print additional pages if needed) ***
Texas Southmost College
High School Relations and Community Outreach
Revised 09/18/2014
Page 2 of 3
Employment History:
Employer
Job Title
Begin Date - (mm / dd / yyyy)
End Date - (mm / dd / yyyy)
Work Performed / Subjects Taught
No. Hours Per Week
Employer
Job Title
Begin Date - (mm / dd / yyyy)
End Date - (mm / dd / yyyy)
Work Performed / Subjects Taught
No. Hours Per Week
Employer
Job Title
Begin Date - (mm / dd / yyyy)
End Date - (mm / dd / yyyy)
Work Performed / Subjects Taught
No. Hours Per Week
*** (For additional information – print additional pages if needed) ***
Texas Southmost College
High School Relations and Community Outreach
Revised 09/18/2014
Page 3 of 3