Form 8405t - Administrative Clear Credential Program (Accp) Enrollment Form - California Division Of Educational Services
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1Division of Educational Services
Leadership Institute of Riverside County
Administrative Clear Credential Program (ACCP)
Enrollment Form
Thank you for enrolling in the Administrative Clear Credential Program sponsored by the Leadership Institute of Riverside
County. We want to make the enrollment process as easy as possible. Please provide the information requested below
and have the form signed by your immediate supervisor in the space provided at the bottom of the page. Mail or fax your
completed form and a copy of your Preliminary Administrative Credential to:
Riverside County Office of Education
Leadership Institute of Riverside County
Attn: Hilma Griffin-Watson, Executive Director
P .O. Box 868, Riverside, CA 95202-0868
FAX: (951) 826-6954
Name: ______________________________________________________________________________________________________
First
Middle
Last
Current Position Title: ___________________________________ School District: ________________________________________
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)
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School or Worksite Name: _______________________________ Office Phone: _________________________________________
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)
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FAX: __________________________________________________
Work Address: _______________________________________________________________________________________________
City
Zip Code
Work E-mail Address: ___________________________________
Home Address: ______________________________________________________________________________________________
City
Zip Code
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)
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Home Phone: __________________________________________ Cell Phone: ___________________________________________
Current Credentials: (A copy of your Preliminary Administrative Credential must be attached to this enrollment form.)
Credential: ______________________________________________________________ Expiration Date: ________________
Credential: ______________________________________________________________ Expiration Date: ________________
Credential: ______________________________________________________________ Expiration Date: ________________
How did you hear about the RCOE Administrative Clear Credential Program? ___________________________________________
Acknowledgements
Candidate: I have read and agree to the conditions of the training and support listed in the ACCP Informational Flyer. I know
that the program fees must be paid in full prior to CTC recommendation for my Clear Administrative Services Credential.
Candidate Signature: __________________________________________________________ Date: _________________________
District Supervisor: I am the above named candidate’s immediate supervisor and certify that the he or she is employed in a
position that requires a California Administrative Services Credential [Ed Code 44270(b) and 44270(a)(2)]. I will support the
candidate in the development of an Individualized Mentoring Plan.
Name: ________________________ Signature: ____________________________________ Date: _________________________
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