PREREQUISITE APPLICATION TEACHING CREDENTIAL PROGRAM FALL 2005 Priority Filing Deadline: March 15, 2005 Final Filing Deadline: April 19, 2005

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1 PREREQUISITE APPLICATION TEACHING CREDENTIAL PROGRAM FALL 2005 Priority Filing Deadline: March 15, 2005 Final Filing Deadline: April 19, 2005 PLEASE PRINT CLEARLY Name Last First Middle Maiden/Former Address Home Phone ( ) Street Unit/Space Include Area Code Work Phone ( ) City State Zip Include Area Code Address: please print exactly (lower/upper case) Social Security # - - Date of Birth / / Gender: M F Ethnic Identity (Optional) University granting Bachelor s Degree: (Gathered for state reporting purposes only) Date of degree or anticipated date: Academic Major: Previously applied to or entered this or other credential program? Yes No List university and year: List Credential(s) held: *If you have held or currently hold a teaching credential, please call and schedule an appointment with a credential analyst to discuss specific requirements you may or may not have to meet. Applying To: Attending: Full-Time OR Part-Time Multiple Subjects Education Specialist: Mild/Moderate Level I Single Subject: English Mathematics Foundational Level Mathematics Science (check one) Biological Sciences Physics Chemistry Geosciences California State University Channel Islands Teaching Credential Program One University Drive, Camarillo, CA (805)

2 Please list ALL colleges and universities attended. ATTACH an official transcript from each, including course work through University extension programs. A cumulative grade point average of 2.67 overall or 2.75 in last 60 units is required Name of Institution Date of Attendance Degree Received If you do not yet have a transcript available with your Bachelor s degree posted at the time of your application, you must submit an official transcript of your work completed to date, and then provide an official transcript with your degree posted and date awarded as soon as it is available. Submit them to the Credential Office and CSUCI Admissions and Records. Personal and Professional Fitness You must answer the question below with either Yes or No. Have you ever been convicted of any felony or misdemeanor offense, including entering a plea of nolo contendere, in the state of California or any other state or country? YES NO Credential applicants are advised that CONVICTION RECORDS may prevent a candidate from obtaining an education credential. Although a wide variety of convictions will not prevent the issuance of a credential, the California Education Code does stipulate that certain conviction records will mandate the denial of a teaching document. Prior to applying, candidates with conviction records should consult with a Credential Advisor from Credential Office regarding the nature of the conviction. STATEMENT OF RESPONSIBILITY: I understand that it is my responsibility to submit all required documents to the Credential Office, accompanying my application, regardless of where else on campus they may have been previously sent. To the best of my knowledge, all information I provide is accurate. I will keep the Credential Office informed of changes in my address, telephone number, , legal name, as well as notify the office of my intent to change programs, or withdraw from a credential program on a temporary or permanent basis. By signing below, I certify I understand these expectations, and am willing to accept responsibility for their completion. SIGNATURE OF APPLICANT DATE Continue to page 3, complete prerequisite checklist and attach all required documents along with application fee of $25.00 California State University Channel Islands Teaching Credential Program One University Drive, Camarillo, CA (805)

3 PREREQUISITE CHECKLIST Prerequisite status enables you to enroll in prerequisite classes. All prerequisite coursework must be completed prior to admission in a Credential Program. The following items are required for prerequisite admission. For further explanation of the following items, please refer to the Information and Application Guidebook. 1. Graduate Application to the University Application has been submitted to the University. Date: Official transcripts from each college or university listed on Page 2 of this Application must be mailed directly to the CSUCI Office of Admissions and Records. 2. Prerequisite Application Application fee of $25.00 attached Official transcripts from each college or university listed on Page 2 attached 3. CBEST Exam CBEST has been or will be taken on and a copy of the score report or registration confirmation attached A copy is required even if you requested your scores be reported to CSUCI. 4. Subject Matter Preparation (CSET exam or approved program waiver) For prerequisite admission you must be registered for a minimum of one subtest. See Information and Application guidebook for details on full admission requirements. CSET exam has been or will be taken on, and copy of score report or registration confirmation attached Copy of exam scores is required even if you requested your scores to be reported to CSUCI. OR *Subject Matter Preparation Program (Waiver) Verification For Single Subject and Special Education Programs only Subject matter preparation program (full waiver or 4/5ths of waiver) completed or anticipated completion at: (University). Semester/Year of completion or anticipated completion: Original waiver letter or 4/5ths letter is attached. Please note that a waiver letter verifying full completion of subject matter preparation will be required in order to recommend you for your credential. * Please see Information and Application Guidebook or program advisor for details California State University Channel Islands Teaching Credential Program One University Drive, Camarillo, CA (805)

4 5. Certificate of Clearance or California Credential/Permit. Submit a completed Character Identification and Clearance (CIC) packet at the time you submit your Prerequisite program application. This packet includes the background check application (Form 41-CIC), completion of Live Scan electronic fingerprinting and accompanying form (Form 41-LS), and money order for $27.50 payable to CCTC. Submission of the packet, when approved by the California Commission on Teacher Credentialing, will result in a Certificate of Clearance document. Attached is one of the following CIC packet with fee Copy of emergency or substitute permit or previous credential Copy of CIC packet which has been submitted to California Commission on Teacher Credentialing Packets are available in the Credential Office, Bell Tower If this packet is not submitted at the time you submit your Prerequisite Application, an original Certificate of Clearance, or copy of a CCTC issued credential must be submitted with your Prerequisite Application. INCLUDE THIS COMPLETED CHECKLIST WITH YOUR APPLICATION California State University Channel Islands Teaching Credential Program One University Drive, Camarillo, CA (805)

5 THE FOLLOWING ITEMS ARE REQUIRED FOR CREDENTIAL PROGRAM APPLICATION See Information and Application Guidebook for details 1. Graduate Application to the University (if not previously submitted) 2. Credential Program Application 3. Official Transcripts with BA/BS degree posted (if not previously submitted) 4. CBEST passing score report 5. Subject Matter Verification Exam(s) passing score report or full waiver or 4/5ths letter from a California University (Single Subject/SPED only) 6. Certificate of Clearance (original) or copy of CA teaching credential/permit 7. Writing Sample 8. Two letters of recommendation 9. Field Experience verification 10. TB Clearance (negative reading) 11. US Constitution course or exam 12. Prerequisite Courses (must have completed or be currently enrolled) California State University Channel Islands Teaching Credential Program One University Drive, Camarillo, CA (805)