Private Vocational Institutions
401 – 1181 Portage Avenue
Winnipeg, Manitoba R3G 0T3
204-945-8507
www.manitoba.ca/pvi
FORM 2 - INSTRUCTOR DECLARATION
SECTION 1 –PROPOSED INSTRUCTOR QUALIFICATIONS
100
Name of Instructor applicant
101
102
ACADEMIC QUALIFICATIONS – Please list your academic qualifications, relevant to the specific course/program
you are proposing to instruct.
Diploma/Degree
103
Institution
Institution
Date Received
TEACHING EXPERIENCE – Please list your teaching experience, relevant to the specific course/program you are
proposing to instruct.
Position Held
Institution
Date (mm/yy)
FROM
FROM
FROM
104
TO
TO
TO
OCCUPATIONAL EXPERIENCE – Please list any occupational experience relevant to the specific course/program
you are proposing to instruct.
Position Held
Institution
Date (mm/yy)
FROM
FROM
FROM
FROM
FROM
TO
TO
TO
TO
TO
SECTION 2 – PROGRAM/COURSE OFFERINGS
Please list the programs offered that you are qualified to instruct (If you are qualified to teach only a specific
course within a program, please indicate that course:
1)
2)
3)
4)
5)
6)
SECTION 3 – DECLARATION OF INTENTION FOR INSTRUCTOR EMPLOYMENT
I,
(name), of
(village/town/city), in the province of [Select one], in the occupation of
, declare
that I propose to be employed as an instructor at the above noted institution; AND am fully qualified to teach the above
noted courses/programs; AND, only if applicable, have a current Renewable Certificate of Qualification/Authorization to
300 Practice from Manitoba Apprenticeship and Certification for the trade of [Select one] .
200
Signature:__________________
Date: (mm/dd/yy):
SECTION 4 – TO BE COMPLETED BY PRIVATE VOCATIONAL INSTITUTION
400
I,
(name), registrant of the above noted institution, hereby declare that the institution has verified that the
qualifications stated by the applicant are accurate AND; as required by Section 13.1 of the Private Vocational Institutions
Regulation, the applicant has provided a criminal record check and a child abuse registry check dated within 3 months
prior to commencing work at the institution.
Signature:_______________________
Received
500
Follow Up Req’d
Date: (mm/dd/yy):
Approved
Meets Regulation Requirements:
12(2) -