Troy State University

Center for Continuing Education

Program Request Form

Title of Program

Date(s) of Program

Time(s) of Program

Number of Contact Hours of Program

Instructor of Record Name & Address

Educational Needs

Rationale of Program

Program Description

Expected Outcome

Targeted Audience

Estimated Number of Participants

Submitted by Program Sponsor

(Signature of Appropriate Department Chair/Dean, see Section VI, C of

the Center for Continuing Education Handbook of Policies and Procedures)

Must be submitted with Instructor of Record Form

For Center for Continuing Education use only:

Course/Workshop Number

Approved

Date