DDPD Course Submittal Form

 
Please complete all information. It is important that we have complete and accurate information for all persons and organizations listed.
Sponsor Information

School/District/

Organization:

Superintendent/CEO:
    Address:
    City:      
    State:     Zip Code: 
Day Phone:    
Fax:   
E-mail Address:

 
Contact Information
Contact Name:
Contact Title:
School/Organization:
    Address:
    City:    
    State:     Zip Code: 
 
Home Address:
    City:  
    State:     Zip Code: 
       
Day Phone:    Evening Phone:
Fax:     
E-mail Address:

 
Course Information
Course Title:    
Credit Hour Request:

   (view credit hour requirements)

If other, please specify: 

Number of Course Contact Hours:    (view contact hour guidelines)
Course Begin Date:    Pick a date Course End Date:    Pick a date
Course Site/City:

Course Designator:

 

   (view course designator guidelines)

If other, please specify: 

Credit Enrollment Estimate:  
 
List all Course Meeting Dates and Times (view academic calendar)

**Please enter only one date per line.  Click "Add more meeting dates" if you have more than six dates.

 Date:   Pick a date    Time: 

 Date:   Pick a date    Time: 

 Date:   Pick a date    Time: 

 Date:   Pick a date    Time: 

 Date:   Pick a date    Time: 

 Date:   Pick a date    Time: 

Add more meeting dates

 
Was this course previously offered?  

Yes  No    

If yes, please indicate when: 

Provide name of instructor previously approved by CMU: 

 

Select the option that applies:

Course syllabus/outline submitted online

Course syllabus/outline on file at CMU

Course syllabus/outline to be mailed to CMU

Course syllabus/outline to be faxed to CMU

 
Instructor of Record Information
Check here if the instructor of record information is the same as the contact information above.
Instructor Name:
School/Organization:
    Address:
    City:    
    State:     Zip Code: 
 
Home Address:
    City:    
    State:     Zip Code: 
   
Day Phone: Evening Phone:
Fax:    
Email Address:
   

Select the option that applies:

Instructor's credentials to be e-mailed to CMU

Instructor's credentials on file at CMU

Instructor's credentials to be mailed to CMU

Instructor's credentials to be faxed to CMU

 
Revenue Sharing Information (view revenue sharing information)
Check here if the revenue-share agency information is the same as the sponsoring agency information above.
Revenue-share Agency:
    Address:
    City:   State:    Zip Code: 
Day Phone:
Fax:   Email Address: 
 

Note:  The revenue share check will be issued to the sponsoring school, district or organization

and mailed to the contact person.

Submit to your district's CMU client services representative: 

Click here to view and print your completed form.  **Please print a copy of this form for your records prior to clicking "Submit/Continue" or "Finished" below.
Click here to submit the Course Submittal Form and begin building the syllabus, course outline and references.
   
Click here to submit the Course Submittal Form only.  You may build the syllabus, course outline and references at a later time. 
   
Click here to reset the Course Submittal Form and begin again.