SPONSORING INSTITUTION

Name:  Northwest Technical College

Street Address (do not list P.O. Boxes) 905 Grant Ave. S

City, State, Zip: Bemidji, MN 56601

Chief Executive Officer (Bemidji State University President)

Name: Dr. Jon Quistgaard

Title: President

Phone: 218-755-2011

Fax: 218-755-2749

E-mail: jquistgaard@bemidjistate.edu

Signature:

Date:

Name: Dr. Charles Giammona

Title: Provost

Phone:218-333-6611

Fax: 218-333- 6695

E-Mail: charles.giammona@ntcmn.edu

Signature:

Date:

Name:  Bruce Hemstad

Title:  Dean of academic and co-curricular affairs

Phone: 218-333-6613

Fax: 218-333-6695

E-mail:  bruce.hemstad@ntcmn.edu

Signature:

Date:

Program director/administrator or Co-Program director/administrator

Name: Julie Dokken RDA CDA

Title:  Program Director

Phone: 218-333-6657

Fax: 218-333-6699

E-Mail: julie.dokken@ntcmn.edu

Signature:

Date: