Free 53621.xls - Indiana

APPLICATION FOR LIBRARY EDUCATION UNIT (LEU) TRAINER PROVIDER
State Form 53621 (5-08)

CERTIFICATION PROGRAM COORDINATOR Professional Development Office Indiana State Library 140 North Senate Avenue Indianapolis, IN 46204-2296 317-234-5650 or 1-800-451-6028 (Indiana only) Fax: 317-232-3713 WWW: http://www.in.gov/library E-mail: [email protected]

For Office Use Only Date Reviewed (month, day, year ) Decision Provider ID Number

PLEASE TYPE
Name of Provider Organization Address (number and street, city, state, and ZIP code ) Telephone number E-mail address Web address

(

) Signature of Authorized Individual
Signature of authorized individual Date (month, day, year ) E-mail address Fax number

Printed name of authorized individual Title Telephone number
( )

(

) Agree Disagree

Our organization agrees to periodic state monitoring of our programs at the discretion of the Indiana Library and Historical Board

Attach agendas for trainings currently offered by the Organization Agendas must include approximate time for each training
Agendas attached (name each course )

Instructors employeed by the Organization Attach resumes or Cirriculum Vitaes for each Instructor
Resumes/CV attached for:

NOTICE: The information you provide will become public record.