Apply for Advancing Substance Use Disorder Counselor Education and Development (ASCEND) Instructor

Please fill out the form below and click "Submit" to submit your application for consideration. Fields with an asterisk (*) are required. To avoid losing your work and to take advantage of saving your answers and finishing the application later, we recommend routinely clicking the "Save & Finish Later" button at the bottom of the page. We look forward to hearing from you.

Summary
Title:	Advancing Substance Use Disorder Counselor Education and Development (ASCEND) Instructor
ID:	1293
Area of Interest:	Healthcare
Contact Information

* First Name	* Last Name

* Country

* Home Street Address

Street address, P.O. box

Apartment, suite, unit, building, floor, etc

* City	* State	* Postal Code

* City	* Other Principal Subdivision
City or town name	Province, state, county, region and/or postal code

* Preferred Phone Number
		()- Ext. Enter numbers only, no dash or parenthesis

* Email Address

Professional Website or LinkedIn Profile

Application Information
* Referral Source:
* Areas of Specialization:
Courses Qualified to Teach:
* Available for Client-Based Instruction:	Yes No Are you available for local travel (within San Diego County) to teach at a client's site?
Attachments
* Resume (or Biobib for UC faculty):	Supported formats: Word, PDF, RTF, Text, and HTML.

	- or Upload from:

GENERAL INFORMATION

* Please provide your name.

* Are you authorized to work in the United States?

	Yes
	No

* Are you related to someone who currently works at UC San Diego?

	Yes
	No

If yes, please provide your family member's name and department where they are employed.

* Are you currently or have you ever been employed by the University of California?

	Yes
	No

If yes, please provide your employee ID.

If yes, please list the UC campuses and departments at which you have been or are employed in any capacity, as well as the dates of your employment. If you have a current academic appointment, please indicate this here. If you are a UC retiree, please indicate this here.

* Are you an active UC Retiree?

	Yes
	No

If yes, please add your date of retirement.

* Are you currently or have you ever been an instructor or guest speaker at UC San Diego Division of Extended Studies?

	Yes
	No

If yes, how are/were you paid?

	Payroll (W-2)
	MarketPlace (1099)
	Other/Unknown

* Are you currently an undergraduate student, a graduate student, or a post-doctoral scholar at any University of California campus?

	Yes, undergraduate student
	Yes, graduate student
	Yes, post-doctoral scholar
	No

If yes, please provide your student ID.

* Are you currently or have you ever been a student at UC San Diego Division of Extended Studies?

	Yes
	No

PROFESSIONAL EXPERIENCE

Education

* Do you have a graduate degree?

	Yes
	No

* If yes, please list your degree(s) and the granting institution(s). If no, please list your highest level of education and the granting institution.

Current Employment

* Name of Organization

* Location

* Title/Role

Teaching Experience

* Do you have any previous teaching experience? This can include experience as a trainer in a corporation or similar positions/roles.

	Yes
	No

If yes, please list the number of years and subjects taught, as well as the format (online vs. in-person) and approximate class size.

Related Experience

* Do you have any licenses or certifications related to the instructor position for which you are applying?

	Yes
	No

If yes, please list the license/certification type, name of the issuing state/professional organization, active/inactive status, and date of expiration.

* Are you an active member of any professional or trade associations related to the instructor position for which you are applying?

	Yes
	No

If yes, please list the organizations.

* Please briefly summarize your professional experience, accomplishments, and industry involvement and how this relates to the instructor position for which you are applying.

REFERENCES

Please provide contact information for four references. We will contact your references by email. Please be sure to enter an accurate, working email address for each reference and let them know to expect a message from us at that address. We will not be able to evaluate your application without four references and accurate, current contact information for each of them.

Name	Title	Company	Phone	Email
*	*	*	*	*
*	*	*	*	*
*	*	*	*	*
*	*	*	*	*

AUTHORIZATION

I hereby certify that the facts set forth in this application and any supplemental information, as well as conveyed during any interview which may be granted, is true and complete to the best of my knowledge. I understand that, if employed, falsified statements communicated at any point in the interview process may be considered sufficient cause for immediate discharge. I hereby authorize, to the extent permitted by law, investigation (confirmation) of all statements contained herein, as well as the employers listed above to give you any and all information concerning my employment and any pertinent information they may have, and to release all parties from all liability for any damage that may result from furnishing same.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for UC San Diego Division of Extended Studies to contract my teaching services. As an academic department within UC San Diego, all Extended Studies Program instructors and courses must be formally approved according to the regulations of the Academic Senate of the University of California. Eligibility to teach a course is contingent upon this formal academic approval. Once approved, teaching assignments are by agreement. The instructors Letter of Agreement outlines the deliverables for the course, the course schedule, and compensation terms, and is subject to department policies and procedures. UC San Diego Division of Extended Studies makes no commitment to hire an instructor until it has sent and received a signed instructor Letter of Agreement. Should the course section an instructor plans to teach be canceled for any reason, the instructor agreement, including rights to compensation for future section meetings, is voided. Remuneration is for classroom hours only and does not include time spent for course preparation or other events.

I further understand that I am responsible for being familiar with all rules and regulations of UC San Diego Division of Extended Studies and for abiding by them. I understand that the UC San Diego Division of Extended Studies has complete discretion to modify its policies, rules, regulations and practices at any time, to the extent permitted by federal, state and local law. By submitting this application, I agree to all instructor Terms and Expectations.

* Signature

* Date

I agree that this form may be electronically signed and agree that my typed signature is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.

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