Form

Accelerated Collaborative Teacher (ACT) Preparation Program

Application for Multiple Subject, Single Subject, or Education Specialist Credential Candidates
ACT Application for:
Full Name
First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

E-mail*
Phone Number
- Area Code Phone Number
Other Phone Number
- Area Code Phone Number
CSUN ID Number
Social Security Number
Gender

Male Female
Age

under 25 25-34 35-44 over 45
Ethnic Identity

Asian or Pacific Islander Black, African American Hispanic/Latino(a) Native American White Other (see below)
Other Ethnic Identity (specify)
Languages in which you are fluent
Undergraduate Major
Institution & Date
Undergraduate GPA (please specify)
Have you submitted a CSUN application through CSUMentor?

yes no
If yes, have you been accepted?

yes no
Have you submitted a credential application?

yes no
If yes, have you been accepted?

yes no
Have you met the writing proficiency requirement (course or exam)?

yes no
Complete the appropriate section
Elementary Education
Have you met the Basic Skills Requirement (CBEST or CSET MS Exam plus CSET Writing Exam)

yes no
Have you met the subject matter requirement (CSET)?

yes no
Secondary Education
Academic Major
Have you met the Basic Skills requirement (CBEST)?

yes no
Have you met the Subject Matter requirement

yes no
If yes, please indicate how this requirement was met:

CSET Subject Matter clearance from an academic program (must have signed subject matter clearance form)
Special Education
Have you met the Basic Skills Requirement (CBEST or CSET MS Exam plus CSET Writing Exam)

yes no
Have you met the Subject Matter requirement

yes no
If yes, please indicate how this requirement was met:

CSET Subject Matter clearance from an academic program (must have signed subject matter clearance form)
Your responses to these questions are used in consideration for admission to the program. Please reflect and write carefully.
1. What experiences have you had with school age children or adolescents?
2. What qualities/attributes do you have that would contribute to becoming a successful teacher?
3. How did you hear about the program?
Signature of applicant (Type name and add date for electronic submission)
Date/Time
/ Month / Day Year
at
: Hour Minutes
Should be Empty:

Accelerated Collaborative Teacher (ACT) Preparation Program

Complete the appropriate section

Elementary Education

Secondary Education

Special Education

Your responses to these questions are used in consideration for admission to the program. Please reflect and write carefully.