Credentialing Committee Review Form Initial or Final Review(Required) Initial Final Reviewer name(Required)Applicant Name(Required)Years of information professional experience post-master's degree(Required)Were the following required documents submitted?(Required) CV or Resume Job Description Diploma or Transcript Level Applying For:(Required) Provisional Member Senior Distinguished Portfolio Coverage Begin DateNot required for initial Provisional application MM slash DD slash YYYY Portfolio Coverage End DateNot required for initial Provisional application MM slash DD slash YYYY Continuing Education (50 points maximum may be claimed)Activity points are not required for initial Provisional applications. You may skip this area for Provisional reviews.CE points: Sponsored LearningIncludes MLA or otherCE points: Academic LearningCE points: Discussion GroupCE points: Self-directed LearningCE Subtotal50 points maximum may be claimedIndividual AccomplishmentsActivity points are not required for initial Provisional applications. You may skip this area for Provisional reviews.Individual Accomplishments: TeachingIndividual Accomplishments: PublishingIndividual Accomplishments: Meeting ParticipationIndividual Accomplishments: Professional Association ParticipationIndividual Accomplishments: Other Professional ActivitiesSubtotal: Individual AccomplishmentsTotal Points Approved:(Required)Enter 0 for Provisional applications.For Senior applicants, are there at least 5 assoc. service activity points? (does not have to be with MLA)n/aYesNoFor Distinguished applicants, are there at least 10 assoc. service activity points including at least 5 MLA activity points?n/aYesNoIs more information (documentation, clarification) needed for you to complete this review? If so, please add notes to the Reviewer Comments section.(Required)YesNoAcademy Level Recommended:(Required)NoneProvisionalMemberSeniorDistinguishedReviewer Comments (add any comments you wish – praise, feedback, missing info):Date portfolio review completed (mm/dd/yyyy)(Required)
