ࡱ> \_[e d:bjbj Labab $$8x*f *******$W, /XB*iB**$$$d*$*$$$#/:j$**0*$e/ne/$$e/$\)"K$cw_)))B*B*")))*e/)))))))))$B f: DATA SHEET Administrative Leadership Programs Please return to: California University of Pennsylvania Office of Graduate Studies & Research 250 University Ave., Box #91 California, PA 15419 Last Name:  FORMTEXT       First Name:  FORMTEXT       MI:  FORMTEXT       Street Address:  FORMTEXT       City:  FORMTEXT       State:  FORMTEXT       Zip:  FORMTEXT       Home Telephone:  FORMTEXT       Work Telephone:  FORMTEXT       Email:  FORMTEXT       Candidate is seeking:  FORMCHECKBOX  K-12 Principal Certification  FORMCHECKBOX  K-12 Principal Certification and Master s of Education  FORMCHECKBOX  Superintendent Letter of Eligibility  FORMCHECKBOX  Superintendent Letter of Eligibility + Doctor of Education in Education Administration and Leadership (EdD)  FORMCHECKBOX  Doctor of Education in Education Administration and Leadership (EdD) (Already hold SLE certification) EDUCATIONAL BACKGROUND Degree/Year Obtained/College-University/Major  FORMTEXT        FORMTEXT       Certification/Year Obtained/College-University  FORMTEXT        FORMTEXT       EDUCATION WORK EXPERIENCES: (List present position first)  Position/Grade/Subject/District/Years  FORMTEXT        FORMTEXT       Professional Organizations: (Include office held, committee, etc.)  FORMTEXT        FORMTEXT       Educational and Community Achievements:  FORMTEXT       List Other Pertinent Achievements:  FORMTEXT       How did you hear about the program to which you are applying?  FORMCHECKBOX Internet Search  FORMCHECKBOX Email  FORMCHECKBOX Mailing  FORMCHECKBOX  Cal U Alumni (please include name of Alumni)  FORMTEXT        FORMCHECKBOX  Friend/Colleague  FORMCHECKBOX Direct 4Z\~ V f p     , }ue}S}#jhhe>*UmHnHujvhhr>*Uhhe>*jhhr>*U#jhhe>*UmHnHujhhr>*Uhhe>*jhhr>*Uheh-heCJaJh`h>CJaJh`heCJaJ h2%5h;/he5h`he5CJaJ\ T B   > F \68gdL0gd2%gd`gde$a$gde, . B D F P R T v x   0 2 4 > yiYjhD$Phr>*UjHhD$Phr>*U#jhhe>*UmHnHujhhr>*Uhhe>*jhhr>*Uj^hD$Phr>*Uhe he>*#jhD$Phe>*UmHnHujhD$Phr>*UhD$Phe>*jhD$Phr>*U"> @ d f z | ~     < > @ ︰︰zog[Ljh>hrCJUaJhL0he5CJaJhL0he5h}8heCJaJjhQahr>*Uh~s#jhQahe>*UmHnHujhQahr>*UhQahe>*jhQahr>*U#jhD$Phe>*UmHnHuj0hD$Phr>*UhD$Phe>*hejhD$Phr>*U@ \ ^ ` b f > B D F H d f h j n {paU{pjh2%CJUaJjh2%CJUaJh>h2%CJaJjh>h2%CJUaJh2%CJaJjthrCJUaJjhrCJUaJh`CJaJh>CJaJh>h>CJaJjh>hrCJUaJjhrCJUaJjhrCJUaJh>heCJaJ! \]klmnp()  $޻zrbzPzzr#jhXhe>*UmHnHujlhXhr>*UhXhe>*jhXhr>*UhejhrUh>he5h}8heCJ aJh {h`6CJaJhL06CJaJh`CJaJjh`CJUaJj\h`CJUaJh>h`CJaJjh>h`CJUaJh2%CJaJ$&(2468Z\^㵥̛̎wk\OjhDhr>*UjD hrhrCJUaJh>he5CJaJh>he5jhe>*UmHnHujhr>*Ujhr>*UjXhXhr>*UhXhe>*heh6'heCJaJ he>*#jhXhe>*UmHnHujhXhr>*UjhXhr>*U\`&NP>,../D0011X1gd>gdQugdeùìÒ~qiYqG#jhDhQu>*UmHnHujB hDhQu>*UhDhQu>*jhDhQu>*Uj hDhr>*Uheh6'heCJaJjhe>*UmHnHujV hr>*Ujhr>*U he>*#jhDhe>*UmHnHujhDhr>*Uj hDhr>*UhDhe>*&(<>@JLNP&<>ʺҨңߖ~laZSZOh~s hqh n hqheh-h42CJaJ#jhaxhe>*UmHnHuj. haxhr>*Uhaxhe>*jhaxhr>*U he>*#jhDhe>*UmHnHuj hDhr>*UhDhe>*jhDhr>*Uheh6'heCJaJ hQu>*jhDhQu>*U>@\^`bdxz|ƾƾݘƾƁtl\tJ#jhaxhT>*UmHnHujthaxha^ >*UhaxhT>*jhaxhT>*Uh}8CJaJjh_CJUaJh6'CJaJj h_CJUaJj h_CJUaJh_CJaJjh_CJUaJh6'h6'CJaJh6'h~sCJaJj h_Uh_jh_U.,...J.L.N.............^/`/ܺԠܺԏܺweVܺjh_CJUaJ#jhaxhT>*UmHnHuj<haxhT>*UhaxhT>*jh_CJUaJUjRh_CJUaJh6'h6'CJaJh6'h~sCJaJjh_CJUaJh_CJaJjh_CJUaJh6'h}8CJaJjhaxhT>*U!Contact w/University  FORMCHECKBOX Conference (please indicate which conference)  FORMTEXT        FORMCHECKBOX  Electronic Banner Ad (please indicate which site)  FORMTEXT        FORMCHECKBOX  Journal/Publication (please indicate which publication)  FORMTEXT        FORMCHECKBOX  Other (please list)  FORMTEXT       Are you a Cal U alumnus?  FORMTEXT       Non-Pennsylvania Students Only Current state of residence  FORMTEXT       Will you be applying for certification in your current state of residence? Check one:  FORMCHECKBOX  Yes  FORMCHECKBOX  No If you are seeking certification in a state other than Pennsylvania, it will be important for you to check with your state Department of Education requirements and whether completing the Administrative Program at Cal U will be accepted. Non-Pennsylvania students who plan to seek Pennsylvania certification are required to notify us of that intent in order to meet the PA certification expectations.Additional information related to Pennsylvania certification can be located at the Pennsylvania Department of Education website. After completing the administrative leadership program, will you pursue certification from the PA Department of Education? Check one:  FORMCHECKBOX  Yes  FORMCHECKBOX  No  I have read and understand the intent to pursue certification statement.  FORMTEXT       Signature / Date      FILENAME \* MERGEFORMAT DataSheetForm.doc Rev. 9/24/2008, 9/25/2009, 12/9/2011, 2/19/2012, 2/28/2013, 5/23/2018, 10/21/2020 `/t/v/x//////////00204060@0B0D0F0b0d0f0r0v000000ڽڽsh`h-CJaJh6'heCJaJjh_CJUaJjhaxhT>*UhX4CJaJjh_CJUaJh_CJaJjh_CJUaJh6'h~sCJaJ#jhaxhT>*UmHnHujhaxhT>*Uj(haxhT>*UhaxhT>*0000000000011 11111"1X111¾|wk_PF9jhaxha^ >*Uh.YB*^Jphh.Yh.Y5B*^Jphh n5B*^JphhX45B*^Jph he>*#jhaxh6%>*UmHnHujvhaxh6%>*Uhaxh6%>*jhaxh6%>*Uhe hqh nh nh`h6'h~sCJaJ#jhaxhT>*UmHnHujhaxhT>*UjhaxhT>*U111111J2L2X2^2b2d22222222222222ھ|q_|q|qM|qCh>B*^Jph#jhqhrCJUaJ#jbhqhrCJUaJhqh nCJaJjhqhrCJUaJhqh nB*^JphhqhJT5B*^JphhqhJTB*^JphhJTB*^Jphh.YB*^Jph#jhaxha^ >*UmHnHujhaxha^ >*Ujhaxha^ >*Uhaxha^ >*X11246Z8\89<9>9B9D9H9J9N9P9T9V9\:^:`:b:d:gde ^`gdKHgdJTgd>24444445567777778888.8dzdz앋~o~`UC`U6hqh nB*^Jph#jJhqhrCJUaJhqh nCJaJjhqhrCJUaJhqhJT5B*^JphhqhJTB*^JphhJTB*^Jphh>h>B*^Jph h nB*fHphq &hqh>B*fHphq &hqh nB*fHphq hJTB*fHphq &h>h>B*fHphq .808L8N8R8T8X8Z8\8^8888889 9 9ƼkUkH@0Hj2haxhKH>*UhaxhKH>*jhaxhKH>*U*h nh nB*CJfHphq *h nh>B*CJfHphq -h nh>6B*CJfHphq -h nh n6B*CJfHphq h>hJTB*^Jphh>B*^Jphhqh nB*^Jph#jhqhrCJUaJhqh nCJaJjhqhrCJUaJ 99999.9:9<9>9@9D9F9J9L9P9R9V9X999999̻̪qmq`NFh6'CJaJ"jhrCJUaJmHnHuh6'CJaJmHnHuh#[\jhrhrCJUaJh'Gjh'GUh>2h>h>B* CJ^JaJfHphq h6B*fHphq hKHB*fHphq &h>h>B*fHphq jhaxhKH>*U#jhaxhKH>*UmHnHu99::,:B:\:^:`:b:d:Ŷh>h'GhBh`h`CJaJmH sH hVaCJaJmH sH h`CJaJmH sH hqCJaJh|CJaJh6'CJaJhh6'CJaJ ~&P+p ,p -p .p 1h/R 4 5 6 7 :p6'/ =!@"@#$ % vDText30tDText2tDText3tDText4vDText32tDText5tDText6tDText7tDText8tDText9tDeCheck1tDeCheck2tDeCheck3tDeCheck1tDeCheck1DdP  3 3"((vDText10vDText11vDText13vDText14DdP  3 3"((vDText16vDText17vDText19vDText19vDText22vDText25tDeCheck4tDeCheck5tDeCheck6tDeCheck7jDtDeCheck8tDeCheck9vDeCheck10vDText25vDeCheck11vDText25vDeCheck12vDText25vDeCheck13vDText25vDText25vDText25tDeCheck1tDeCheck1tDeCheck1tDeCheck1vDText25 s666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ OJPJQJ_HmH nH sH tH @`@ eNormalCJ_HaJmH sH tH DA D Default Paragraph FontRiR 0 Table Normal4 l4a (k ( 0No List H @H e0Footer H$CJaJmHsHtH>/> e0 Footer CharOJPJQJ^J44 |0Header H$:/!: |0 Header Char CJ_HaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vc:E3v@P~Ds |w<v \ L , > @ $>`/012.8 99d:  "#$%X1d: ! "(;GMWcis/0Uef\lm)/1=Cu  &lx~IYl|"@P8DJL\t [ k l v & 6 7 A Q R \ FFFFFFFFFFGGGGGFFFFFFFFFFG G G G FG G G FG FG FG FFFGGGGF (:L# @0(  B S  ?!Text30Text2Text3Text4Text32Text5Text6Text7Text8Text9Check1Check2Check3Text10Text11Text13Text14Text16Text17Text19Text22Text25Check4Check5Check6Check7Check8Check9Check10Check11Check12Check13_GoBack<Xt V2vmJmAM ]   )Nj1g0D'Z}#Q] ] o o ] ] ?*urn:schemas-microsoft-com:office:smarttags stockticker WZ  Z ] ^f W Z ] 33-);NWjs1Tg01Du'l  IZl}#@Q8KL]t  5 X ] -);NWjs1TUg01Du'l  IZl}#@Q8KL]t  @ X ] &\`Q 47&bQjyr~`@CZx  C" z a^ _ H #~KHV*B>D$-}8@&$F;mpQub6( 4 Kh $!)!1B!#}#}N$%I?%u%+&?&>A'|J'wL'P(p(@"*9*Y:*[+Md-!.j.P~/~/"F0L0I142i2I*3@>3ok4D 5.56,9 :91:|:LP;<$<s=~9>?f?F@`@=AOB)D/DjEODF'GHiHpHkIvJ)UKMtM)Nn?N4QQnSTJTuzT U[V3W}W+XYY.Y2[![F)[#[\D]$b]^-^t^U``'aVadb d&esefVIg~h()ipik9k0l"ulFmem n n5n-]oq%3rVs,sGs<~uAwwMw_VwPxvx yyfhzz{F |}~T~8l;yO_]E 8^0o@N["?BKDGL'^$Xy\ m3I"!:XRe = SfpwV|5(f"j=8gPh6*RgDzB5flT(G|%)\]D4P||10FP^_S*3T( ?~6'%4|4{qk>Z/$[aX4[Uy$x~s;xHSQk36Z], p/&|]G JueY e-N-x0|qaL[dqc6%7g/6|:*u 1}[i_`j 2%YC.!2j*/TXZqeyk[ 4dsIw) @d****\  @.UnknownG.[x Times New Roman5Symbol3. .[x Arial5. .[`)Tahoma7.*{$ CalibriA$BCambria Math"1h2Gg   !@20 3QHP  $Pe2!xx campbellWagner, Kristen Oh+'0`   ( 4@HPX campbellNormalWagner, Kristen9Microsoft Office Word@q@"@HB  ՜.+,0  hp  (California University Of Pennsylvania   Title  !"#$%&()*+,-./012456789:;<=>?@ABCDEFGHIJLMNOPQRTUVWXYZ]^bacldefghijkmRoot Entry F#/`Data '1Table3e/WordDocument LSummaryInformation(KDocumentSummaryInformation8SMsoDataStore@-9.FQL2OUKKIITEMA==2@-9.Item  2PropertiesUMacros9.#/VBA 9.9.  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGIJKLMNOPQRSTWXYZ[\^ 1rxME ThisDocument _VBA_PROJECT] dirH PROJECTwmU)(S"SS"<(1Normal.ThisDocument8(%HxAttribute VB_Name = "ThisDocument" Bas1Normal.VGlobal!SpaclFalse CreatablPre declaIdTru BExposeTemplateDeriv$Custom izC1a  *\G{000204EF-0000-0000-C000-000000000046}#4.2#9#C:\PROGRA~2\COMMON~1\MICROS~1\VBA\VBA7.1\VBE7.DLL#Visual Basic For Applications*\G{00020905-0000-0000-C000-000000000046}#8.7#0#C:\Program Files (x86)\Microsoft Office\Office16\MSWORD.OLB#Microsoft Word 16.0 Object Library*\G{00020430-0000-0000-C000-000000000046}#2.0#0#C:\Windows\SysWOW64\stdole2.tlb#OLE Automation*\CNormal*\CNormalQi~a4*\G{2DF8D04C-5BFA-101B-BDE5-00AA0044DE52}#2.8#0#C:\Program Files (x86)\Common Files\Microsoft Shared\OFFICE16\MSO.DLL#Microsoft Office 16.0 Object Library*\G{0D452EE1-E08F-101A-852E-02608C4D0BB4}#2.0#0#C:\Windows\SysWOW64\FM20.DLL#Microsoft Forms 2.0 Object Library*\G{5276395A-64D1-4537-AD90-727F1B0931E8}#2.0#0#C:\Users\wagner_k\AppData\Local\Temp\1\Word8.0\MSForms.exd#Microsoft Forms 2.0 Object Library.E .`M  i~a 1ThisDocument05617e69dcThisDocumentr jGNY`&WordkVBAWin16~Win32Win64xMacVBA6#VBA7#Project1 stdole`Project- ThisDocument< _EvaluateNormalOfficeuDocumentjMSFormsC CheckBox1`"$ (0* pHdProjectQ(@= l i~a J< rstdole>stdoleP h%^*\G{00020430-C 0046}#2.0#0#C:\Windows\SysWOW64\e2.tlb#OLE Automation`ENormalENCrmaQF  *,\C QmA!OfficgODficg!G{2DF8D04C-5BFA-101B-BDE5gAAe42ggram Files (x86)\Common \Microsoft Shared\OFFICE16\MSO.DLL#P 16.0 Ob LibrXary'zMSF@Cs> MSFDs3@eD452EE1-E08"F1A-8-02608C4D0BB4eFM20L'B @r&/;"1ă} Ã00}#0ƒ# 50 A5276395A-64D1-4537-AD90-727F1B0 931E86Users\wagner_k\AppData\Local\Temp\1\Word8.0d9.exde>#.E .`(M B"1ThisDocumentGT isDmcuen 2` Hj1z",Qr""+ThisDocumentThisDocumentID="{0FA42568-81F0-4C96-A6B2-4FC810DC5236}" Document=ThisDocument/&H00000000 Name="Project" HelpContextID="0" VersionCompatiPROJECT VCompObj]rble32="393222000" CMG="FAF83350C054C054C054C054" DPB="8B8942C3D2C4D2C4D2" GC="1C1ED576F706F806F8F9" [Host Extender Info] &H00000001={3832D640-CF90-11CF-8E43-00A0C911005A};VBE;&H00000000 &H00000002={000209F2-0000-0000-C000-000000000046};Word8.0;&H00000000   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q