CAMPUS DIRECTOR FORM SCHOOL NAME: LOCATION: City

CAMPUS DIRECTOR FORM
SCHOOL NAME:
LOCATION:
City/Town
Your School must submit one form for the Campus Director of your school. The Campus
Director is the principal administrator at the school. The school also must submit a new Campus
Roster (POSA AP Page 19) in conjunction with each successive addition or deletion of a
Campus Director. Print Clearly.
CAMPUS DIRECTOR: __________________________________________________________
Beginning Date: ________________________________________________________________
Mailing Address:
Street:
__________________________________________________
__________________________________________________
City, State Zip:
__________________________________________________
Office Phone:
____________________
E-mail _____________________________
The Campus Director must complete each question below.
Connecticut Regulations of State Agencies Section 10a-22k-5(k)(1) requires that "The director
of a school" meet the following criteria:
1) I hold a high school diploma, or other equivalency
recognized by the Board of Education (G.E.D.)
and
2) I have a minimum of five years experience in the area
for which training is offered.
or
I hold an undergraduate diploma from a four-year college
and
I have a minimum of three years of experience in the area
of training being offered.
or
If the school offers instruction in an area in which
I am not qualified, the department head or supervising
instructor shall have the above qualifications.
and
(3) I am experienced in administration, if yes list number
Of years____________
(7/2013 Rev)
Yes
No
Yes
No
Yes
No
N/A
Yes
No
N/A
Yes
No
POSA AP Page 23
EDUCATION AND EXPERIENCE: Attach a current copy of your resume.
1) EDUCATION - You must provide at a minimum this information on education:
- Institution name and address/location
- Major subject studied
- Degree/Diploma/Certificate name and date awarded
2) EXPERIENCE - You must provide at a minimum information on
a) relevant experience in the area for which training is offered, and
b) experience in administration:
- Employer name and address/location
- Position held and duties and responsibilities involved
- Beginning and ending dates including month and year
Teacher Certification (if applicable) - attach a copy of teaching license and detail here the
subjects in which authorized to give instruction:
Occupational License (if applicable) - attach a copy of current license and detail here area(s)
licensed in:
DISCLOSURE:
Indicate any prior involvement as required by Connecticut General Statute Section 10a-22c,
amended by Public Act 11-48, as a director with a postsecondary career school in Connecticut or
any other state which school had its certificate of authorization revoked or privilege to carry on
vocational instruction canceled by the state:
Name of State__________________________________________________________________
Initial the correct answer below:
No Prior Involvement
Yes, Prior Involvement complete the following information
Name of School ________________________________________________________________
Full Address ___________________________________________________________________
Position(s) Held at School ________________________________________________________
Period Employed _______________________________________________________________
Date of Revocation or Cancellation of Privilege to Operate ______________________________
(7/2013 Rev)
POSA AP Page 24
Reason for Revocation:
school ceased to meet conditions of authorization
school committed a material or substantial violation of Statute Section 10a-22a
to 10a-22k, amended by Public Act 11-48, or 10a-22u to 10a-22w of the Regulations
school made a false statement on a material fact in its application
school failed to make a required payment to student protection fund
other reason
unknown reason
I do swear or affirm that the statements made on the Campus Director Form are complete
and correct to the best of my knowledge and belief.
Signature of Campus Director
Date
It is the responsibility of the school to ensure that it hires an appropriately qualified individual,
pursuant to Regulation of State Agencies Section 10a-22k-5(k)(1), to act as Campus Director of
the school. The Executive Director of the Office of Higher Education may waive the educational
and other requirements for a director where there is other evidence of qualification. If applicable,
attach documentation showing the grant of a waiver.
I do swear or affirm that the statements made on this form are complete and correct to the
best of my knowledge and belief.
Signature of School Director
Name of School Director
(7/2013 Rev)
_______
Date
______
POSA AP Page 25