Instructor Name:                   Department:       

Instructor's Email:                 Phone#:               

Please indicate two choices for dates that you would like the class to take place (enter MM/DD/YY).

1st Choice:                             2nd Choice:         

Course Name:                        Course #:            

Number of Students:              Time:                   

Student Classifications: Freshmen    Sophomore Junior    Senior Graduate

Please give any additional information that will help us provide your students with the most beneficial instruction session:                               

North Carolina Agricultural and Technical State University
Greensboro, North Carolina 27411