The Credential Student Service Center charges a fee for an evaluation and signature to be used for renewal of Emergency Permits. Please complete this form and submit to the Credential Student Service Center, AE 235 with a personal check, payable to CSUH. WE CANNOT ACCEPT CASH.

FEES ARE: $15.00 Processing fee for three-day service
                  $25.00 Fee for next day service
 

Name:____________________________________  Date:_____________________

Address:_____________________________________________________________

Telephone:____________________________ Social Security No.:___________

Type of Credential____________________________________________________

Amount attached:_____________________________________________________

This fee is earned upon receipt and is non-refundable. The above fee does not include the regular fees required for each credential application assessed by the Commission on Teacher Credentialing.

Date logged:_________________  Initials:__________