ASD Certificate/License Declaration Form

Please complete the following items in order to clarify your intentions concerning the ASD certificate and Licensure programs. It is important that we have your current contact information and that we also know which ASD program you intend to complete so that we can provide appropriate advising and an accurate program audit to support your program completion.
* Required

Personal Information

ASD Program Completion Options

Please Indicate which ASD program you intend to complete, which will enable us to send you completion information appropriate for that program. Check one of the following:

Please return completed form no later than June 21, 2013 to:

Molly Doran, Program Administrator MS-A1720 1536 Hewitt Avenue St. Paul, MN 55104 Fax: 651-523-2489

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