SB 2042-PRELIMINARY APPLICATION – UNIVERSITY INTERN OPTION
MULTIPLE AND SINGLE SUBJECT PROGRAMS
California State University Dominguez Hills
Teacher Education Division
(310) 243-3496
Deadline Dates*:
Spring Term: October 1
Summer Term: Last Friday of March
Fall Term: April 1
*NOTE: Deadline dates are subject to change.
Obtain information about the Teacher Education Program:




Attend optional Information Session
Access TED website (csudh.edu/soe/index.html)
Purchase appropriate TED Program Handbook and Class Schedule at the university bookstore
Make an appointment to meet with a faculty advisor at the Teacher Education Division (310) 243-3496
Preliminary Application Process
1. Apply to the university online at: www.csumentor.edu
2. Submit “Petition for Exception” if your baccalaureate GPA is below 2.75 in the last 60 units or below 2.67 overall. (Form
may be obtained in the Student Services Center, SCC 510)
3. Submit Preliminary Application to TED Program
 Preliminary Application Form
 District Certification of Pre-Service Preparation and Applicant Certification of Pre-Service Preparation and District
Support Form (Back page of application form)
 Official transcripts of all college course history with degree posted
 Verification of subject matter competence-Photocopies of PRAXIS, SSAT and/or CSET exams. Single Subject
Candidates ONLY: If you have completed subject matter competency you must submit the ORIGINAL letter.
 Check or money order for $50.00 payable to CSUDH (non-refundable).
 Verification of Basic Skills: Copy of passing CBESTcard and scores; or copy of passing scores on CSET: Multiple
Subject Plus Writing Skills Examination or copy of scores of “college ready” or “exempt” on CSU EAP Placement
exams in Math and English or copy of score of 50 on CSU ELM Placement Test and score of 151 on CSU EPT
Placement Test.
 Submit a copy of valid contract of employment from a school within CSUDH service area
 Copy of emergency, substitute permit, pre-intern credential or Certificate of Clearance (packets available at the Student
Services Center SCC 510)
 Evidence of current negative TB test results (no older than 4 years at the time of start term)
 Verification of U.S. Constitution requirement by course or test (highlight course on transcript)
 For Bilingual Emphasis only: Passage of at least oral verification must be met at the time of submitting application;
written fluency and culture knowledge must be submitted for advancement into “Phase I” of the program.
 Apply for the University Intern Credential (see below for additional items and instructions)
4. Submit all materials to the Student Services Center, SCC 510. NO INCOMPLETE APPLICATIONS WILL BE
ACCEPTED! Allow 3-6 weeks for program application processing.
5. For questions/status regarding program application contact the Application Unit at (310) 243-3530 and for questions
regarding your University Intern Credential contact the Credential’s Office at (310) 243-3353.
6. Receive letters of acceptance from both the University and from the Teacher Education Division.
7.Register for classes via MyCSUDH
University Internship Credential:
IMPORTANT: You must have an email address and be able to use a credit card (MasterCard or Visa) for payment.
 Credential Request Form (attached)
 Intern Survey (attached)
 Verification of pre-service classes (TED 400, TED 411 and TED 407)
 Once the Credential Office has submitted the online recommendation you will be emailed by CCTC to complete the Personal and
Professional fitness and payment portions of the process. After that task is completed within two working days CCTC will send you
notice of receipt. (All correspondence will take place via email.)
 Within an additional two working days you will receive confirmation that your credential has been granted, providing there are no
extenuating circumstances. Confirmation will come from CCTC and may be taken to a school district for employment purposes.
 Your actual credential will be granted and sent via email directly from CCTC.
NOTE: Your application for the two-year University Internship Credential will not be processed until you have completed
your University Intern Option Application are both admitted by the university and the program and are registered for
courses.
Revised 7/09
SB 2042-PRELIMINARY APPLICATION-UNIVERSITY INTERN OPTION
California State University Dominguez Hills
Teacher Education Division
Application Date:
Starting Term:
Student SSN/ID:
DOB:
Office use only
CSUDH TEACHER EDUCATION
Processing Fee: __________________
Check/Money Order: ______________
Date Received: ___________________
Name:
Last Name
First Name
M.I.
Former Name (if applicable):
Ethnicity:
Gender:
Male
Female
Email:
Home Phone:(
)
Work Phone:(
)
Mailing Address:
Street
Credential Option: (Check one)
Multiple Subject
Multiple Subject Bilingual
City
State
Zip Code
Single Subject- Subject Area:
Single Subject Bilingual -Subject Area:
School District:
School Phone: (
)
School Name:
School Address:
Street
City
State
Grade Level(s) Assigned:
Zip Code
Subject Area(s) (Single Subject only):
Language of Instruction:
Instruction conducted in bilingual classroom: Yes
Previously admitted to a credential program? No
Yes
If yes, where
1. List colleges/universities attended and attach transcripts from each:
Colleges/Universities Attended
From
To
Undergraduate Degree Major:
Units Earned
No
_
When?
Degree Posted
Minor:
2. Verification of Basic Skills
3. Verification of full-time employment: Attach Contract or Employment Letter verifying employment period ( i.e. 8/1/01 - 6/30/02)
4. Copy of Current Emergency, Substitute Permit, Pre-Intern Credential or Certificate of Clearance
5. District Certification of Pre-Service Preparation and Applicant Certification of Pre-Service Preparation and District Support Form
6. Evidence of current negative TB test results (no older than 4 years at the time of start term)
7. Verification of U.S. Constitution requirement met by:  Exam (letter attached)
 Course (highlighted on transcript-grade of “C” or better)
8. Subject Matter Verification: (Check one)
I have met the subject matter requirement in the following way:

Examination(s): (Attach test scores)
1.
2.
3.
4.

Exam Name:
Exam Name:
Exam Name:
Exam Name:
Date Taken:
Date Taken:
Date Taken:
Date Taken:
Single Subject Candidates ONLY: Subject Matter Equivalency Program (Attach advisor verification form)
Subject Area:
9. For Bilingual Emphasis only: Passage of at least oral verification must be met at the time of submitting application; written fluency and culture
knowledge must be submitted for advancement into “Phase II” of the program.
I understand that I am responsible for knowing and adhering to TED program and University regulations and policies. I understand that
my acceptance into the TED Credential Program is dependent upon my acceptance into the university.
Signature:
Date:
7/09
PRELIMINARY APPLICATION-UNIVERSITY INTERN OPTION, cont.
(Required for University Intern candidates)
DISTRICT CERTIFICATION OF PRE-SERVICE PREPARATION AND SUPPORT
(To be completed by school administrator)
Name of Applicant:
I certify that the above-named individual was provided with an orientation to teaching at his
or her assigned level, including an overview of curriculum, classroom instruction, and
effective techniques of classroom management.
I certify that the above-named individual has been assigned to an experienced educator to
guide and assist him or her.
I certify that the above-named individual will be provided with opportunities to observe and
participate in other classrooms while enrolled in the California State University, Dominguez
Hills credential program.
Signature of Principal:
Date:
Print Name of Principal:
Name of School:
District:
APPLICANT CERTIFICATION OF PRE-SERVICE PREPARATION
(To be completed by TED credential program applicant)
Directions: Circle the number that best describes the extent to which the pre-service training provided by your
district prepared you for assuming classroom responsibilities. Write comments in the brief space provided.
Pre-service Training
Not Helpful
Extremely Helpful
Orientation to Teaching
1
2
3
4
5
Overview of Curriculum
1
2
3
4
5
Classroom Instruction
1
2
3
4
5
1
2
3
4
5
Classroom Management
Comments:
Signature of Applicant:
Date:
California State University, Dominguez Hills, Credential Office
Credential Request Form
Applicant’s Full Legal Name (as it will be printed on your credential document) and mailing address: (Please print clearly)
(First)
(Middle)
(Street)
(Last)
(City)
Social Security#:
(State)
(Zip code)
E-mail address:
(Attention: Please do not use AOL or sbcglobal.net or socal.r email addresses)
Date of Birth:
Daytime Phone: (
/
/
All Former/Maiden Name(s):
)
Work Phone: (
)
CSU Dominguez Hills, College of Education congratulates your recent credential achievement; you have completed a major milestone in your
professional career. In an effort to maintain contact with you and to assure accurate information in our existing database, we ask that you please take a
few moments to complete the following.
Teaching or Services information:
Employing School District:
School:
Subject(s):
Grade Level(s):
Please check the credential for which you are initiating a request. (Complete one form per request)
Multiple Subjects

Ryan

SB 2042

SB 2042 (BCLAD)

Intern

Intern (BCLAD)

Preliminary

Professional Clear

Supplementary or Subject Matter Auth
Single Subject:







Ryan
SB 2042
SB 2042 (BCLAD)
Intern
Preliminary
Professional Clear
Supplementary or Subject Matter Auth

Professional Clear Tier II
Pupil Personnel Services

Intern

School Counseling

School Psychology

Child Welfare and Attendance
Special Education
 Certificate of Eligibility Mild/Moderate
 Certificate of Eligibility Moderate/Severe
 Preliminary Level I Mild/Moderate
 Preliminary Level I Moderate/Severe
 Prof Clear Level II Mild/Moderate
 Prof Clear Level II Moderate/Severe
 Certificate of Eligibility Early Childhood
(Does not have a job)





Preliminary Level I Early Childhood
Prof Clear Level II Early Childhood
Early Childhood Certificate
(Prof Clear Education Specialist credential required)
Intern Mild/Mod or Mod/Severe or Early Childhood
(Circle one)
Resource Specialist Certificate
(LH or SH and Regular Education credential required)
For Office Use Only
Issuance date
CDS Code
$50 Process fee rec’d
Processed by
Administrative Services

Certificate of Eligibility (does not have a job)

Preliminary Tier I
Intern Program Consent Form, 2008-2009
-4-
The Intern Program is a state-funded program of support and
preparation for public school teachers to earn a teaching
credential. By completing this consent form, you will join your
local Intern program.
It is important to collect information on new public school
teachers as we work to address the teacher shortage, provide
support for new teachers, and promote teacher retention. The
California Information Practices Act and the Federal Privacy Act
provide that agencies requesting information indicate the
principal purposes for which that information is used.
Information gathered on this consent form will be used to
determine funding for your Intern program.
I agree to participate in the Intern Program during the 20072008 school year.
School Name______________________________________
I estimate that I will complete my intern program
(month)____, (year)____
4. For the year immediately preceding entering the
internship credential program, please indicate which one
of the following career categories best defines your
experience:
Military (Armed Forces)
Technical & Scientific Industries (e.g. engineering)
Social Services ( e.g. health related, government
 Other business or industry ( e.g. sales, legal,
clerical, manufacturing)
 College/University (recent graduates)
 Paraprofessionals ( e.g. classroom aides)
 Provisional/Emergency/Substitute Permit Holders
 Other Teaching ( e.g. private school, college)
 Other ___________________________
(list job)
School District _____________________________________
Intern Program ____________________________________
Type of Intern Program MS SS Sp Ed
1. First Name _________________________________
Last name__________________________________
Email address (if available) _______________________________
2. What is your gender?
Male
Female
What is your birth date? __/__/__
5. What is your ethnicity?
 African American or Black
 Asian American/Asian/Indian (e.g. Chinese,
Japanese)
 Latino, Latin American, Puerto Rican, Mexican
American, Chicano or other Hispanic
 SE Asian American/SE Asian (e.g. Cambodian,
Hmong)
 Pacific Islander, Filipino
Caucasian (non-Hispanic)
 Native American/Alaskan Native
 Other__________________________________
3. Is this your first year in the Intern Program? Yes  No
If No, is this your 2nd or 3rd year in the Intern
program?
Questions 6-10 are on the back of this page
6. When and where did you receive your undergraduate
degree?
Year graduated college ____
In California

Outside California
 UC
Which state? ________
 CSU
Or Country? _________
 Private Institution
8. What grade level(s) do you teach this year? (Mark all that apply).
Pre K
K 1
2
6
8
10 11 12
7
9
3
4
5
9. What subject(s) are you assigned to teach this year?
(Mark all that apply—select the options that best describe your assignment)
Please indicate campus ____________________________
7. Please indicate the credential you are working toward:
Multiple Subject
 Single Subject (Mark all that apply)
 Agriculture
 Art
 Business
 English
 Languages other than English
 Health Science
 Home Economics
 Industrial & Technology Education
 Mathematics
 Music
 Physical Education/Dance
 Science (Biological, Chemistry, Physics and Geo
Sciences)
 Social Science (History, Economics, Government, other)
 Education Specialist
 Mild Moderate
 Moderate Severe
 Deaf/Hard of Hearing
 Visually Impaired
 Physical Health Impairments
 Early childhood
 Other ______________________________
Multiple Subject
 Elementary, self contained
 Middle School Core
 High School
 Single Subject (Mark all that apply)
 English ( e.g., writing, literature, journalism, yearbook, drama, speech)
 Mathematics ( e.g., general, algebra, geometry, statistics, trig, calculus)
 Science (e.g., general, biology, chemistry, physics and geology)
 Social Science ( e.g., history, economics, government, geography,
civics)
 Physical
Education & Dance
other than English
 Languages
 Art
 Music
 Agriculture
 Business (e.g., computers, data processing, business law, bookkeeping)
 Health
 Home
Economics
Arts/ROP
 AVID, or other similar assignment
 Industrial
 Education Specialist
 RSP ( e.g., Collaborative, push in/pull out)
 SDC
 Itinerant
 Transition
 Assistive Technology
 ECSE
10. What is your Social Security Number?
-
-
(required to track the Intern Program/s funding) _____________________
Please return this form to your Intern Director