SCHOOL DIRECTOR FORM SCHOOL NAME: LOCATION: Your

SCHOOL DIRECTOR FORM
SCHOOL NAME:
LOCATION: _________________________
Your school must submit one form for the School Director. The School Director has responsibility and
control over the main campus and any branches. The school must submit School Director Form as part
of the application for initial approval or renewal approval. Print clearly.
The school must submit a revised Campus Roster (POSA AP Page 19) in conjunction with each
successive addition and deletion of a School Director.
SCHOOL DIRECTOR NAME: ______________________________________________________
Beginning Date: _____________ E-mail Address _______________________________________
QUALIFICATIONS:
The School Director must complete each question below.
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________________
Yes
No
Yes
No
Yes
No
N/A
Yes
No
N/A
Yes
No
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
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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 - attach a copy of teaching license and detail here the subject(s) in which
authorized to give instruction and any expiration date:
None or N/A
Occupational License (if applicable) - attach a copy of current license(s) and detail here area(s)
licensed in and any expiration date(s):
None or N/A
DESIGNATION OF QUALIFIED INDIVIDUAL IN EACH APPROVED SUBJECT AREA
OFFERED:
Your school must list all approved subject areas in which instruction is offered.
(A) Subject Area
(B) Indicate if Director is
Qualified in Each Area
Answer Yes or No
If No, Complete Column (C)
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
(C) Name of Department Head
or Supervising Instructor
Who meets requirements
for Subject Area
(in lieu of Director)
Please attach an additional sheet if needed.
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
cancelled by the state:
Name of State__________________________________________________
Initial the correct answer below:
No Prior Involvement
Yes, Prior Involvement, complete the following information:
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Name of School
Full Address
Position(s) Held at School
Period Employed
Date of Revocation or Cancellation of Privilege to Operate
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 School Director Form are complete and
correct to the best of my knowledge and belief.
Signature of School Director
Date
_______________
It is the responsibility of the school to ensure that it hires an appropriately qualified individual,
pursuant to Regulation 10a-22k-5(k)(1), to act as 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 the School Director Form are complete and correct to
the best of my knowledge and belief.
Owner Signature:
Name of Owner/Majority Owner of School:
(7/2013 Rev)
Date:
(Print)
POSA AP Page 22