California University of Pennsylvania | Cal U
DATA SHEET
Administrative Leadership Programs
Please return to:
California University of Pennsylvania
Office of Graduate Studies & Research
250 University Ave., Box #91
California, PA 15419
Last Name: First Name: MI:
Street Address: City: State: Zip:
Home Telephone: Work Telephone: Email:
Candidate is seeking:
K-12 Principal Certification
K-12 Principal Certification and Master’s of Education
Superintendent Letter of Eligibility
Superintendent Letter of Eligibility + Doctor of Education in Education Administration and Leadership (EdD)
Doctor of Education in Education Administration and Leadership (EdD) (Already hold SLE certification)
EDUCATIONAL BACKGROUND[pic]
Degree/Year Obtained/College-University/Major
Certification/Year Obtained/College-University
EDUCATION WORK EXPERIENCES: (List present position first)
[pic]
Position/Grade/Subject/District/Years
Professional Organizations: (Include office held, committee, etc.)
Educational and Community Achievements:
List Other Pertinent Achievements:
How did you hear about the program to which you are applying?
Internet Search
Email
Mailing
Cal U Alumni (please include name of Alumni)
Friend/Colleague
Direct Contact w/University
Conference (please indicate which conference)
Electronic Banner Ad (please indicate which site)
Journal/Publication (please indicate which publication)
Other (please list)
Are you a Cal U alumnus?
Non-Pennsylvania Students Only
Current state of residence
Will you be applying for certification in your current state of residence? Check one: Yes No
If you are seeking certification in a state other than Pennsylvania, it will be important for you to check with your state Department of Education requirements and whether completing the Administrative Program at Cal U will be accepted.
Non-Pennsylvania students who plan to seek Pennsylvania certification are required to notify us of that intent in order to meet the PA certification expectations. Additional information related to Pennsylvania certification can be located at the Pennsylvania Department of Education website.
After completing the administrative leadership program, will you pursue certification from the PA Department of Education? Check one: Yes No
“I have read and understand the intent to pursue certification statement.”
Signature / Date
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