June 5, 2022
Exhibit A
DIVISION OF ELEMENTARY AND SECONDARY EDUCATION REQUEST TO PRESENT A TRAINING PROGRAM TO SCHOOL BOARD MEMBERS
Please compile the following information and submit it electronically via the Division's website:
Pursuant to Section 6.03 of the Division of Elementary and Secondary Education Rules Governing Required Training for School Board Members (Rule), program providers must submit a detailed description of the entire program, including staff qualification, to the Department to be received at least thirty (30) days prior to the date of the program. This deadline will allow for review of the program to determine whether training and instruction credit pursuant to Ark. Code Ann. § 6-13-629 and this Rule may be awarded.
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Address ______________________________________________________________
Phone Number: ________________________________________________________
Fax: _________________________________________________________________
E-Mail _______________________________________________________________
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_______________________________________________________________________
Address: _________________________________________________________
Phone Number ____________________________________________________
Fax Number: ______________________________________________________
E-mail: __________________________________________________________
List qualifications to present program (include relevant educational background, work experience, examples of similar programs presented, etc.):
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Address: _________________________________________________________
Phone Number ____________________________________________________
Fax Number: ______________________________________________________
E-mail: __________________________________________________________
List qualifications to present program (include relevant educational background, work experience, examples of similar programs presented, etc.):
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Address: _________________________________________________________
Phone Number ____________________________________________________
Fax Number: ______________________________________________________
E-mail: __________________________________________________________
List qualifications to present program (include relevant educational background, work experience, examples of similar programs presented, etc.):
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Address: _________________________________________________________
Phone Number ____________________________________________________
Fax Number: ______________________________________________________
E-mail: __________________________________________________________
List qualifications to present program (include relevant educational background, work experience, examples of similar programs presented, etc.):
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Address: _________________________________________________________
Phone Number ____________________________________________________
Fax Number: ______________________________________________________
E-mail: __________________________________________________________
List qualifications to present program (include relevant educational background, work experience, examples of similar programs presented, etc.):
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Address: _________________________________________________________
Phone Number ____________________________________________________
Fax Number: ______________________________________________________
E-mail: __________________________________________________________
List qualifications to present program (include relevant educational background, work experience, examples of similar programs presented, etc.):
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Submitted by: __________________________________Date: ________________________
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FOR DESE USE ONLY
Date Provider Information Received ______________________________________________
Date Reviewed: ______________________________________________________________
Request to Present Program: Approved: __________________________________________
Denied: ____________________________________________
Date of decision: _____________________________________________________________
Signature of DESE Representative: ____________________________
005.28.22 Ark. Code R. 009