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* 1. First and Last Name:

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* 2. Email Address:

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* 3. Phone Number:

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* 4. Interested Academic Discipline: (I hold a Master's degree with 18 Graduate hours in the following Discipline)

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* 5. Are you available to teach during the day?

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* 6. How did you hear about this event?

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* 7. I can come prepared with application materials (resume/cover letter & unofficial transcripts/certifications)

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