University of Central Arkansas
   


Academic Outreach
Course Request Form

All of the colored fields are required before
submitting this form.

*Your Name::
*Your Department:
*Your Email:
*Your Phone:

*Department
requesting course:
*Department Chair:

*Course Prefix &
Number:
ex. "ABCD1234"
*Course title:
*Semester:

If the course begins or ends off-schedule,
please indicate the start date and end date.
Start/End date:

 to

*Meeting time:
ex. "MWF 1200-1250"
*Location Room:
*Location Building:
*Location Town:

*Is class grant funded? No   Yes
If yes, Grant No.:

*Max enrollment No.:
*Will AOEP control enrollment?

 No   Yes
*Section comments:
ex. Prerequisites, contacting instructors,
campus meetings, etc.
*Delivery method:
(Include CV sending site if Compressed Video)
ex. Classroom, WebCT, online,
compressed video, etc.
*Instructor Name:
*Instructor Title:
*Instructor ID:

*Instructor Address:
*City:
*State:
*Zipcode:

*Phone:
*Email:

*Instructor is?

 Full Time   Part Time
*Load:

 Part of Load   Overload
*Salary:
*Salary guaranteed? No   Yes
If guaranteed, instructor will get whole amount
no matter number of students enrolled.
*Will Instructor need travel? No   Yes

*Denotes required field

  

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University of Central Arkansas   201 Donaghey Ave   Conway, AR 72035-5003 
For general inquiries or comments, call 501-450-3118, fax 501-450-5277, or email Academic Outreach & Extended Programs.