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HrJf !, fORLIVE SCANSERVICE{Im/Applicant SubmissionA0281ORI:f;vc,S',,;/1t?T1nn-1t r m,fI f /Job Title or Type of License, Certification or Permit:/,CJ.I 'vt c,r /lIft c o/ 1e1tl"v f'tf/!'11vd7.;; r hrl/1o/'rr /-:rt, Ardlr.rffType of Application:Code assigned by DOJ // ;,-,,.,, f.J /4vfILicense/Certification/PermitTEACHER CRED 44340 ECIAgency Address Set Contributing Agency:CASM TEACHER CREDENTIALING03294Agency authorized to receive criminal history InformationStreet No.1900 Capitol AvenueCA Name of Applicant:(Please print) Alias:Zip CodeContact Telephone No.LastFirstLast*Sex:D*Height:MaleD FemaleMisc. No. BIL -*Weight:IMl*Driver's License No:First*Date of Birth:1Contact Name (Mandatory for all school submissions)95811-4213States.c,1on 2Mall Code(five-digit code assigned by DOJ)Street or PO BoxSacramentoCityISection 1-L t4Vt pfA41(Section 3I--Agency Billing NumberMisc. Number:*Home Address:*Eye Color:*Hair Color:--Street No."Place of Birth:City, State and Zip Code*Social Security Number (full):*OCA Number:7ktlvt Srff11(SSN OR !TIN#)* Required Fields{)ptnrf«w,I/ c,fYf;ltff.Level of Service:If resubmission, list Original ATlNumber:SUPt'1 -· -- ·TAL AGENCY/EMPLOYER(County Office of Educau [t,wtEmployer NameStreet No. StateLive Scan Transaction Completed By:Transmitting Agency[KJ( )Agency Telephone No. (optional)Sc 11/tV,t/ r,w11lr/t t1,,'f ftt/;W/LSIDfr,o r/JA,).Ile , -hrr/2#w ;1-r1ATINo.---FBISection 5----- ------Name of Operator;Y/vJIDOJJ/1111 kZip CodeLivt[K]j S.ctlon4 IfMalleCode(COE/SDc --Street or PO Box----DateISectionAmount Collected/BilledORIGINAL - Live Scan Operator; SECOND COPY - Applicant; THIRD COPY (if needed) - Requesting Agency61

Live Scan LocationsBelow is a list of local Live Scan agencies available to the public. Applicants ore encouraged to contactthe Live Scan agencies in advance to verify their current operating hours, fees, and method of payment.You may visit the California Deportment of Justice website for additional Live Scan agency locations athttps: //oag.co.gov /fingerprints/locationsAgency Contact InformationHoursFeesCal Poly Pomona University Police Dept.3801 W. Temple Avenue, Bldg. l 09Pomona, CA 9 1 768(909) 869-6738Monday - Thursday:8:00 am - 4:00 pm Walk-insFriday:8:00 am - 4:00 pm Appt. onlyRolling 20DOJ 32FBI l 7Total Fees 69Mail N' More dbw/ Certfix385 S Lemon Ave, EWalnut, CA 93291(909) 468- 1 5 1 1 /(800) 7 1 0- 1 934, Ext linfo@certifixlivescan.comMonday - Friday:8:30 am - 6:00 pm Walk-insSaturday:9:00 am - 4:00 Walk-insRolling 25DOJ 32FBI 1 7Total Fees 74UPS Store (next to Stater Bros)20687 Amar Rd. #2Walnut, CA 9 1 789(909) 444- l 303httg:LLwalnut-ca-4029.theugsstoreloca I.comLMonday - Tuesday8:30 am - 7:00 pm Walk-insWednesday - Friday9:00 am - 7:00 pm Walk-insSaturday9:00 am -4:00 pm Walk-insMonday - Friday:8:00 am - 6:30 pm Walk-insSaturday:9:00 am - 4:00 pm Walk-insRolling 25DOJ 32FBI 1 9Total Fees 76Rolling 25DOJ 32FBI 1 9Total Fees 76Monday - Thursday:9:00 am - 6:00 pm Walk-insFriday:9:00 am - 4:00 pm Walk-insRolling 22DOJ 32FBI 1 7Total Fees 71Monday - Friday:9:00 am - 6:00 pm Walk-insSaturday:9:00 am - 5:00 pm Appt. onlyRolling 24DOJ 32FBI 1 7Total Fees 73UPS Store1 1 42 S. Diamond Bar BlvdDiamond Bar, CA 9 1 765(909) 8 6 1 -240 1 /(800) 7 1 0- 1 934, Ext linfo@certifixlivescan.comUS Live Scan1 43 E. Rowland St, Suite 1Covina, CA 9 1 723(626) 967-0473uslivescan@yahoo.comWest Covina Live Scan Fingerprinting666 S. Sunset AveWest Covina, CA 9 1 790(626) 851 -9723Disclaimer of EndorsementMt. San Antonio College does not endorse or affirm the quality of products or services provided by the abovereferenced companies. The information provided is believed to be reliable and while every effort is made to assure thatthe information is as accurate as possible, Mt. San Antonio College at no time endorse nor recommends any specificcommercial products, process, or services by trade name, trademark, manufacturer, or otherwise, and does notnecessarily constitute or imply its endorsement, recommendation, or favoring by Mt. San Antonio College.

n'Tra in'f gCDTC Live Scan Reimbursement RequestForm 2021-2022"mcn,0Conrnrtillm1. * Legal Name (First and Last):I13. *Last Five Digits of Social Security Number:2. * Birthdate (mm/dd/yyyy):4. *Applicant Email:5. *Issue Check to: ermit Applicant (check will be issued using name above)DDEmployer Name oOther Agency/ohu-K w,!I It 1rJJ/tl /, l!Y.I",.,, ency:Employer/Agency Email:Emplo"nr111 6. *Mail Check to:7Ly Phone:-----Address:City:--------------- ----------State:Zip code:7. I hereby certify that this Live Scan Reimbursement Request Form is true and correct,and that an acceptable receiptis attached, documenting the actual costs.*Applicant's Signature:*nDate:Include ORIGINAL RECEIPT or Livescan Form 41-4* showing the paid Live Scan fees.*Form 41-LS form must show amount paid in Section 6 of the form.A. Only first-time permit applicants that have not had CTC prints done before are eligible to apply forthe Live Scan fee reimbursement.B. Only FBI and DOJ fees (currently 49) are reimbursed. Additional agency fees are not eligible forreimbursement.C. Only the permit applicant, their employer, or other agency can receive reimbursement payments.D. The reimbursement request form must be submitted as part of a complete permit application packet.E. Reimbursement payments are processed on a first come, first served basis. Funding is limited;submission of this request form does not guarantee a reimbursement payment.F. Please allow 4-6 weeks for processing; check will be issued from the Yosemite Community CollegeDistrict.(See more detailed CDTC Stipend Permit policies at www.childdevelopment.org.)Submit this completed Live Reimbursement Request Form with your permit application packet.For assistance, email CDTC-Permit@yosemite.eduFor CDTC Staff Use OnlyStaffInitials:* Req uired FieldsIApprovedPayment:CDTC FPR Form Revised 07/01/21

APPLICATION FOR CREDENTIAL AUTHORIZING PUBLIC SCHOOL SERVICEMail application and payment(check or money order) to:(For Privacy Act Notification see Application Instructions)!HE/County/District Use OnlyCommission Use Only: Fee InformationFP1.IssuanceDate:OtherPERSONAL INFORMATION (type or print)Email:CTC Use OnlyI *Date of Birth: (mm/dd/yyyy)j*Social Security or Individual Tax Identification Number *My Full Legal Name:-1Route to:Commission on Teacher CredentialingCertification Division1900 Capitol AvenueSacramento, California 9581 1 -4213APPAppeal:\FirstMiddleAll Former/Maiden Name(s):\LostCounty/District of Employment (CA only):*Address:I *State:*City:Home Phone:*Zip:Mobile Phone:Work Phone:I*Email Address:* Required Information2. APPLICATION TYPE REQUESTED: (select only one option)Q New Credential/PermitQExtension by Appeal Qupgrade (Clear Credential or Child Development Permit)QAdd Subject/Authorization to Existing Document Q change of RestrictionQRenewalQ other:3. CHOOSE DOCUMENT TYPE: (make only one selection in this section)* Available at the request of a California Local Education Agency (LEA) only. Documents ;n bold font requ;re youto select from Sectfon 4 below a Subject or Authodzed Area of Servke to be Usted on the document.ING CREDENTIALS:0 Single· tO Multiple Subject0 Education SpecialistQ career Technical (CTE)SERVICES CREDENTIALS: EMERGENCY PERMITS*:O Administrativeii PersonneluageQ Adult Education0 Other:O Limited Assignment*Q short-Term Staff*Q Provisional 11 - ·-·'"O EMQEL -lAV(,,e(J( ti K.SUBSTITUTE PER0 30-DaLC 'I t, flt.·CHILD DEVELOPMENTPERMITS:areer Substitute*Q AssistantQProspective Substitute QAssociate TeacherQTeaching Permit for QTeacherStatutory Leave*Q Master TeacherQ 30-Day CTE SubstituteSite SupervisorProgram DirectorChildren's CenterPermitOschool-AgeEm hasisOO04. SELECT AUTHORIZATION/SUBJECT AREA(S): (to choose additional subject areas, see page 5 "Comments" box)ntary TeachinEnglish Learner AuthorizationCLAD CertificateOsupplementary Authorization/Subject Matter AutCTC Use OnlyCTE Industry Sector:FORM 41-4 (REV. 5/2021 )

5. CHILD DEVELOPMENT PERMIT RENEWAL SELF-VERIFICATIONAs the holder of a Child Development Permit (any level except the Associate Teacher Permit) you must complete a specific number ofplanned and approved professional growth activities for each five-year renewal. These activities must be recorded on the ProfessionalGrowth Plan and Record form. As the holder of a Child Development Permit choosing to self-verify completion of these requirements,you may be subject to an audit. The Commission reserves the right to request submission of these forms for auditing purposes anytime within one year following submission of this application. If the Commission determines through its audit that you did not completethe professional growth requirements, your permit will not be renewed and you may be subject to adverse action on other credentialsyou currently hold. You must retain your Professional Growth Plan and Record form for one year following the submission of thisapplication. ,f.;:; iI cert1,. ,LtAvt )l111k,I v,v / trAfr! f,mtp -,11/ffl lt/lfl11'! "ll/;'c,r4f.are) that I have read the above and completed the following for this renewal of my ChilI have com p leted6. PROFESSIONAL FITNESS QUESTIONSAnswers to the following questions are required. If you answer yes to any question, you must complete thecorresponding Professional Fitness Explanation Form.Before granting your application, the Commission will review, at a minimum: Federal Bureau of Investigation criminal history (rap sheet)California Department of Justice criminal history (rap sheet)International database of teacher misconduct maintained by the National Association of State Directors ofTeacher Education and Certification (NASDTEC)Previous reviews by the Commission//v;t// C{y tJhrh1f th") (I4t1fWW- '1fComplaints from othersr"' /'/v t::I /I {"WUNotifications from school districtstr CC vn1 ft /Teacher preparation test score violations-L Ml/ 1/'u mv-J / " ;t"f,1// ft j'No;vtu11. / frYou must disclose misconduct, even if: fu- ftJnfl,f /'f'ex/Y Fifnr ff t::-')(//l'/ // ll/;h'J r ff/1-9jt? ;/- -EP .It happened a long time agoIt happened in another state, federal court, military or jurisdiction outside the United StatesYou did not go to court and your attorney went for youYou did not go to jail or the sentence was only a fine or probationYou received a certificate of rehabilitationYour conviction was later dismissed (even if under Penal Code section 1 203.4), expunged, set aside or thesentence was suspended&WARNING: You will be required to sign your application under penalty of perjury; by doing so you are alsostating that you understand: That the information you provide is true and correct; That you understand any and alt instructions related to your application; Failure to disclose any information requested is falsification of your application and the Commission mayreject or deny your application or take disciplinary action against your credential; The Commission may reject your application if it is incomplete and it will be delayed.FORM 41 -4 (REV. 5/2021 )2

a. Have you ever been: dismissed or, non-reelected or, suspended without pay for more than ten days, or retired, or resigned from, or otherwise left school employmentbecause of allegations of misconduct or while allegations of misconduct were pending?Q Yesb . Have you ever been convicted of any felony or misdemeanor i n California or any other place?You must disclose: all criminal convictions misdemeanors and felonies convictions based on a plea of no contest or nolo contendere convictions dismissed pursuant to Penal Code Section 1203.4 driving under the influence (DUI) or reckless driving convictions no matter how much time has passedYou do not have to disclose: misdemeanor marijuana-related convictions that occurred more than two years prior to this application, exceptconvictions involving concentrated cannabis, which must be disclosed regardless of the date of such aconviction. infractions (DUI or reckless driving convictions are not infractions)Q Yesc. Are you currently the subject of any inquiry or investigation by any law enforcement agency or any licensing agencyin California or any other state?Q YesQNod. Are any criminal charges currently pending against you?Q Yese.Have you ever had any credential, including but not limited to, any Certificate of Clearance, permit, credential,license or other document authorizing public school service, revoked, denied, suspended, publicly reproved, and/orotherwise subjected to any other disciplinary action (including an action that was stayed) in California or any otherstate or place?Q YesFORM 41-4 (REV. 5/2021 )3

f.Have you ever had any professional or vocational (not teaching or educational) license revoked , denied, suspended,and/ or otherwise subjected to any other disciplinary action (including an action that was stayed) in California or anyother state or place?Q ves7. CHILD ABUSE AND NEGLECT MANDATED REPORTINGAs a documentholder authorized to work with children, it is part of my professional and ethical duty to report everyinstance of child abuse or neglect known or suspected to have occurred to a child with whom I have professional contact.I understand that I must report immediately, or as soon as practicably possible, by telephone to a law enforcementagency or a child protective agency, and will send a written report and any evidence relating to the incident within 36hours of becoming aware of the abuse or neglect of the child.I understand that reporting the information regarding a case of possible child abuse or neglect to an employer, supervisor,school principal, school counselor, coworker, or other person is not a substitute for making a mandated report to a lawenforcement agency or a child protective agency.I understand that the reporting duties are individual and no supervisor or administrator may impede or inhibit myreporting duties.I understand that once I submit a report, I am not required to disclose my identity to my employer.I understand that my failure to report an instance of suspected child abuse or neglect as required by the Child Abuse andNeglect Reporting Act under Section 1 1 1 66 of the Penal Code is a misdemeanor punishable by up to six months in jail orby a fine of one thousand dollars ( 1 ,000), or by both that imprisonment and fine.I acknowledge and certify that as a documentholder, I will fulfill alt the duties required of a mandated reporter.DI agree8. EMPLOYING AGENCY INFORMATIONCounty CDS Codebe completed for all credential, cer ficate, and permit types where service is restricted to an emCharter School/Non-Public ScL-t,1V(;f)/1r I( (School District CDS Code- '----------- ;;-· s, Provisional Internship Perm , ort-Term Staff Permits, Limited AssignmentApplications for One-year Nonrenewable CrPermits, and Emergency Permits, "'"'"'' 30-Day or Prospective Substitute Teaching Permits ,t be filed through the employingagency. Employers me an annual Declaration of Need for Fully Qualified Educators on file witsubmissioapplications for Limited Assignment or Emergency Permits.Before submitting, please review the application for completeness:1)Personal information with correct SSN, date of birth, and email address filled in on page 12)Type of credential clearly marked on page 1 (use box below for additional subject/authorization requests)3) Alt Professional Fitness Questions marked Yes or No on pages 3 and 44)Read and agreed to your responsibilities as a mandated reporter5)Payment (check or money order attached to the front of this form). See Credential Leaflet CL-659 for feeschedule.FORM 41-4 ( REV. 5/2021 )4

Checks or money orders may be made payable to the Commission on Teacher Credentialing. The Commission doesnot accept cash payments. All application fees are non-refundable.Applications submitted that are incomplete or without the appropriate fee included will not be processed and willbe returned., ,.,f. /),, .i'" / 1--rtvrJ Iit -tlackTn* Int J 15 q tt-91t v'f,l{A/t11 vn ·9. OATH AND AFFIDAVIn1/P-h1i15[V11 ,,,/l 111r ccu 1/e . I solemnly swear (or affirm) that I will support the Constitution of the United States of America, the Constitution of the State ofCalifornia, and the laws of the United States and the State of California. I hereby certify (or declare) under penalty of perjuryunder the laws ofthe State of California that all the foregoing statements in this application are true and correct.DateI(mm/dd/yyyy)ICity . . Coun ty State(where you sign the form)SIGNATURE OF APPLICANT* You must complete all portions of this section.Comments/Additional Subject Requests:FORM 41a-4 (REV. 5/202 1 )5

Tra 111f gConsartiuaao moamaanlapaacntChild Development Permit ApplicationVerification of ExperienceWhen applying for a Child Development Permit with Option 1, experience must be verified by submittingthis Verification of Experience form or an original letter from the employer on official letterhead.» Have em ployer or supervisor COJDAlete this form to verify the required experience.» Submit additional Verification of Experience forms if needed to reach the required total number of days.» Verification of experience must accompany all other required permit application documents, DO NOTmail separately to the Child Development Training Consortium (CDTC) or the California Commission onTeacher Credentialing (CTC).» E-signature is accepted ; form may be signed, scanned and printed. Signature may not be typed.*This is to verify/certify that:--------------------------(Name of Permit Applicant)Has served in an instructional capacity in a child care and development program the following dates:*Start Date:------------(Month/Vear)*In the position of:*With children ages:*Seeking Permit Level:DDD*End Date:(Month/Vear or Present)(Job Title)Has the required days of experience: Within the last:Associate Teacher50 days, at least 3 hours per day2 YearsTeacher175 days, at least 3 hours per day4 YearsMaster Teacher350 days, at least 3 hours per day4 YearsDSite Supervisor350 days, at least 3 hours per day,including 100 days supervising adults4 YearsDProgram DirectorOne year of site supervisor experience*Verified by (initials):Check below, only if individual has completed less than the required number of days for permit level listedabove, write the total number of days and initial:DTotal number of days worked or

For specific information regarding the CA Child Development Permit Matrix, go to childdevelopment.org . or call (209) 572-6080. First Time Applicant . Tr a f r l f ri lo pm e n, Consortium g Permit Application Checklist 2021-2022 Program Year . Use checklist below when submitting application packet: