index3.htm

	Name First Name Last Name
	Date Month Day Year
	Home Address City State Zip Code
	Email
	Home Phone
	Cell Phone
	Work Phone
	Current Position/Location (Subject and School)
	Undergraduate Degree (What, Where, & When)
	Current Certifications held
	Current Endorsements held


	Written Statement DIRECTIONS: Complete this statement on a separate page using 1 inch margins, 12 point font, and double-space. Bring this form and the statement with you to the informational meeting being held on Tuesday, May 26^th, 2009 at FIU’s South Campus, Deuxieme Maison Room 110.
	Explain how you believe this program will support your professional goals of working with students with autism.

Project PEACE Application