APPENDIX 2

CALIFORNIA STATE UNIVERSITY, SAN BERNARDINO

COLLEGE OF EDUCATION

Application for Admission to the Educational Administration Program

(Please Print Clearly )

Name: _____________________________________________________________________________________

                     Last                      First                        M.I.                                                      Student ID Number

Other names that may appear in your records: ______________________________________________________

Date of Birth: _____________________

Mailing Address:   _______________________________________________________________________

      __________________________________________________________________________________

Home Telephone #: (___ ) _______________________ Work Telephone #: (___ ) _____________________   

E-mail address:_______________________________   Fax #: (_____)________________________________

Employer Name:   _______________________________________________________________________

______________________________________________________________________________________

                      Address                                                                 City                                        Zip

Credentials held and where obtained:

__________________________________________________________________________________________ __________________________________________________________________________________________

When do you plan to begin the program(s) Quarter: _________   Year: ________

INDICATE BELOW WHICH PROGRAM(S) YOU ARE APPLYING FOR: Check appropriate option(s)

_____   Preliminary Administrative Services Credential (Tier I)

Tier I Attachments :

•  Photocopy of Calif. Teaching Credential

•  Letter from District Personnel Office indicating one year of teaching.

•  Photocopy of successful completion of CBEST test.

•  Reference Forms (2)

Tier II Attachments :

•  Photocopy of valid Prelim Admin. Service Credential

•  Letter from District Personnel office documenting present employment in an Administrative position

•  Verification of Completion of a Masters Degree

•  Reference Forms (2)

_____ Preliminary Admin Services Credential (Tier I) & Masters Degree in Educational Administration

WRITING PRE-REQUISITE required for the Preliminary Credential and/or Master's Degree candidates

has been met by one of the following options:

Expository Writing Class:

CSUSB 306/495 Quarter : F__ W    Sp     Su         Year: _____ Grade _____

Equivalent: Approval Date _____________ (Attach copy of Univ. Approval)

Passed WREE Exam: Date ______________ (Attach copy of Certification)

_____   Professional Administrative Services Credential (Tier II)         

I hereby certify under penalty of perjury that the foregoing is true and correct.

____________________________________________   __________________________________

Signature               Date

Send your completed application with all attachments stapled in a set to:

California State University, San Bernardino

Records, Registration & Evaluation, College of Education,

Masters & Advanced Credentials Office UH-171, Attn: Laura Duarte

5500 University Parkway, San Bernardino, CA 92407-2397