________________________________________________________________________________________
  Lastname                                              Firstname                            Middle/Former/Maiden

 ________________________________________________________________________________________
  Street                                                                City                        State            Zip

_________________________________________________________________________________________
Social Security Number                        Home Phone                                    Work Phone

1.    Please indicate the type of Emergency Permit you currently hold:

____ Multiple Subject
____ Single Subject in: (Authorized Field)_________________________________________________
____ Special Education (Type)_____________________________________________________________
____ Other: _______________________________________________________________________________

2. List all California Credentials ever held_________________________________________________

___________________________________________________________________________________________

3. Have you been admitted and enrolled in a credential program? ____Yes ____No
    If yes, when, where and status? ________________________________________________________

__________________________________________________________________________________________

4. Have you been evaluated for a subject-matter program? ____Yes  ____No
    If yes, you must submit a copy of your subject matter examination.

5. Have you taken a subject matter examination? ____Yes  ____No
    If yes, you must submit a copy of your subject matter examination.

I understand that the request for Emergency Permit Renewal Services in no way guarantees me a credential or obligates CSUH to provide me with whatever I lack to earn that Credential nor does this constitute formal admission into a credential program or admit you to the University.

__________________________________________________________________________________________
        Date                                                                        Signature
 
 

REQUIREMENTS:

Candidates requesting to renew an Emergency Permit must complete the following procedures:

1.    Completion of Processing Fee Form and check or money order payable to CSUH.
        ____$ 15.00 fee for (3) day service
        ____$ 25.00 fee for next day service*

2.    Completed Request for an Emergency Permit Renewal Form (Information above) and a copy of your current emergency credential.

        ___ Please check if you would like the Credential Student Service Center to mail the CL_469 form to you.

3. Copy of CBEST, Praxis exams, SSAT exam, verification of subject-matter program evaluation, U.S Constitution exam (if applicable).

4. Copies of all college transcripts including Bachelor's degree or higher from each college attended.

    List all colleges attended.

    ______________________________________________________________________________

    ______________________________________________________________________________

    ______________________________________________________________________________

* Next day service: If you submit your application by 1:00 p.m., your signed CL-469 and evaluation will be ready for you by 5:00 p.m.
the following weekday. Applications submitted after the 1:00 p.m. deadline will be ready for pick up by 5:00 p.m. two workdays after the application date. Fees are earned upon receipt and are non-refundable. This fee does not include any University fees nor fees assessed by the California Commission on Teacher Credentialing.