Name:                                                                                                

District        :                                                                                        

School:                                                Grade/Subject:                                

Social Security #:                                        Birth Date:                                

Type of Credential:                                Expiration Date:                                  

        CA Preliminary Single Subject                        Out of State

        CA Preliminary Multiple Subject                Years Teaching Experience                

        CA Preliminary Education Specialist

*Please attach a copy of all current teaching credentials*

Person Verifying Credential:                                                                                

Title:                                                  Location:                                                

Contract Start Date:                                                                                        

As an eligible teacher, I have been informed of my responsibility to enter a professional teacher induction program within 120 calendar days of the start of my initial teaching contract date, and provided with information about program requirements and expectations.

                                                                                                

                Signature                                                        Date

Having been informed, as stated above, I chose not to participate in the Madera Unified School District Madera Induction Consortium Program.  I plan to obtain my Professional Clear Credential in the following manner.

                                                                                                                                                                                                                

                                                                                                        

                                                                                                

Signature                                                        Date

JS 2016

Madera Unified School District