Computer Science Supplementary Authorization (CSSA) Program Application

Application Instructions

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.

Name:

(Maiden Name, Previous Name)

(mm/dd/yyyy)

Please provide the email address that you check in summer

Home Address:
Phone:

Credential and Teaching Experience Information

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

Status of Teaching Credential:
Type of credential:

Name of school in which you are currently employed as a teacher (enter N/A if not currently at a school site)

Is this a Title I school?:
Previous Student?:

Have you ever attended Sacramento State for an academic credit degree program, certificate, or other?

If you are a previous student, what is your Sacramento State Student ID (SID) number?

NOYCE Recipient:

Are you a NOYCE recipient?

What is your institutional affiliation that provided your NOYCE award? Noyce recipients in the Western Region are eligible for reimbursement.

(1000 characters left)

Submit a copy of your credential

If you're a current student, upload a copy of your credential program admission letter. If you're an in-service teacher, upload a copy of your credential (PDF or photo are acceptable). If you need to obtain a copy of your credential, you can log into your account through the CTC website (you may register an account if you have not yet set this up), view your documents, and select your current credential document.  Click “email document” and a copy of that document should automatically be sent to your email account on file with your CTC account. You may not get a notification or pop up alerting you that it has been sent, but after clicking “email document” simply check your email account.  

Additional Information

I certify:

Participation in, or successful completion of, the Computer Science Supplementary Authorization (CSSA) program does not confer any national or state credential or license and is not a guarantee of employment. 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.

Application Fee:

An application fee of $30 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

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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