Pupil Personnel Services Credential Application

Application Instructions

Sealed official transcripts of all colleges and universities attended, other than Sacramento State MUST be mailed to:

Attn: PPSC program
College of Continuing Education
3000 State University Drive
Sacramento, CA 95819-6103

Please note: * (asterisk) Indicates a required field.

Applicant Information

Personal information included on this form will be kept confidential in order to protect against unauthorized disclosure.

First

Middle

Last Name

(Maiden Name, Previous Name)

(mm/dd/yyyy)

Address 1

Address 2

City

State

Zip

Home

Work

Cell

Have you ever been convicted, including a conviction based on a plea of no contest, of a felony or misdemeanor in California or any other state? You must disclose your conviction even if the case was dismissed pursuant to Penal Code Section 1203.4. You may omit misdemeanor marijuana-related convictions that occurred more than two years prior to this application, except convictions involving concentrate cannabis, which must be disclosed regardless of the date of such conviction.

Academic Preparation Add More

Please include the names of all colleges and universities attended. Begin with the last institution attended. An official transcript must be submitted for each college and university, other than Sacramento State.

Name

Enrolled From (mm/dd/yy)

Enrolled To (mm/dd/yy)

Employment Information

Please list current place of employment, organization or agency.

Additional Information

I certify under penalty of perjury that I have provided complete and accurate responses to the items listed on this application. I further certify that all official documents submitted in support of this application are authentic and unaltered records that pertain to me. I have read and agree to comply with the statements listed above.

An application fee of $50 will be collected after eligibility has been determined. You cannot be enrolled into the program until the application fee has been collected.

Demographics

The College of Continuing Education at Sacramento State is committed to providing equal opportunity in education. A critical element of our commitment to diversity lies in our ability to collect and assess student demographic data. Your response to the voluntary student demographic information would be very helpful and much appreciated

Voluntary Student Demographic Information

Please identify your age

Please identify your gender

Please identify your ethnicity origin and/or race

Please identify your highest degree or level of education

Privacy Policy:

The College of Continuing Education respects your right to privacy. Any information given to us when requesting course or program material will be used solely for the purpose of answering or responding to your request. We do not sell or otherwise distribute your personal information. We may, however, use it to provide you with advanced notices of our course offerings. If at any time you wish to be removed from our mailing lists, you may contact us and your request will be processed immediately.

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