DATA SHEET
Administrative Program for Principals/Superintendent Letter of Eligibility
Please return to:
California University of Pennsylvania
Office of Graduate Studies & Research
250 University Ave., Box #91
California, PA 15419
Last Name:
Street Address:
Home Telephone:
First Name:
City:
State:
Work Telephone:
MI:
Zip:
Email:
Candidate is seeking:
K-12 Principal Certification
K-12 Principal Certification and Master’s of Education
Superintendent Letter of Eligibility
EDUCATIONAL BACKGROUND
Degree/Year Obtained/College-University/Major
Certification/Year Obtained/College-University
EDUCATION WORK EXPERIENCES: (List present position first)
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
__ 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? ___
219548024
Rev. 9/24/2008, 9/25/2009, 12/9/2011, 2/19/2012, 2/28/2013
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
219548024
Rev. 9/24/2008, 9/25/2009, 12/9/2011, 2/19/2012, 2/28/2013