Credential Request Form – 2013/2014
For Multiple and Single Subjects, Education Specialists and Career/Technical Education Credential Holders
As a reminder, successful completion of the Tri-County Induction Program (TCIP) (additional evidence is required for preliminary Education Specialist + CTE credential holders) is required in order to obtain a Clear Credential.
Upon successful completion of all program requirements, Karen McLaughlin, ED. D, Director of the TCIP, will direct Kathy Tamez, SCSOS Credential Analyst, to submit an ONLINE recommendation to the California Commission on Teacher Credentialing (CCTC). Candidates will then follow the application and payment procedures through an automatically generated email. You MUST have a valid email address. Please note: AOL addresses are not currently accepted. This email provider blocks CCTC automated-reply emails. Use a nearby relative or school email account if you are an AOL member.
1. Please PRINT CLEARLY using blue/black ink. Provide the following required information:
Applicant’s Full Legal Name (as it will be printed on your credential document)First / Middle / Last
All Former/Maiden Name(s):
Social Security #: / Date of Birth:
Type of Credential(s) for which you are applying:
o Multiple Subjects o Single Subject o Authorized Subject(s): ______
o Education Specialist M/M o Education Specialist M/S o Career/Technical Education
Mailing Information: (Where you want your credential document to be sent.)
Street Address:
City: / State: / Zip Code:
Contact Information: PRINT CLEARLY (must use an email available in the summer)
Email (no AOL addresses):
Home Phone: / Work or Cell Phone:
School Site: / District:
· Some Ryan Credential teachers are required to complete a CPR class. The CPR class MUST be in Infant, Child, and Adult CPR. Please submit 1 copy of both sides of your CPR card with this form.
· Teachers holding Designated Subjects/Career Technical Education, and/or Ryan Credentials (including out of state), partially meet credential requirements through the Tri-County BTSA Induction Program. Discuss with your County Credential Analyst.
· Out-of-state trained applicants may have additional requirements including CBEST, CSET, US Constitution, RICA or a Reading Class listed on your credential. Discuss with your County Credential Analyst.
· If you would like to add an authorized subject(s) to your clear credential, please provide a copy of your CSET result(s) or a copy of your official transcript(s).
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