Form Cl 469 – Fill Out and Use This PDF

State Of California	Telephone:
Commission On Teacher Credentialing	(888) 921-2682
Certification, Assignment and Waivers Division	E-mail: credentials@ctc.ca.gov
Box 944270	Website: www.ctc.ca.gov
Sacramento, CA 94244-2700

EMERGENCY PERMIT RENEWAL VERIFICATION FORM

(CL-469 CLAD-BCLAD)

CROSSCULTURAL, LANGUAGE AND ACADEMIC DEVELOPMENT (CLAD) PERMIT

BILINGUAL, CROSSCULTURAL, LANGUAGE AND ACADEMIC DEVELOPMENT (BCLAD) PERMIT

This form must be completed and submitted with each application packet for renewal as specified in Commission leaflet CL-533O CLAD-BCLAD and must be accompanied by a completed application (form 41- REN) and processing fees. The employing agency must have an annual Declaration of Need for Fully Qualified Educators (form CL-500) on file with the Commission.

Applicant’s Name: __________________________________________________________________________

Social Security Number: _____________________________________________________________________

PART I - Employer’s Verification of Orientation, Guidance and Assistance

Orientation to Teaching (required for first renewal only)

I certify that the above-named individual, while serving on the emergency permit for the first time, was provided with orientation specific to the authorization on the permit, including an overview of curriculum, classroom instruction, and effective techniques of classroom management at the assigned level.

Guidance and Assistance (required for all renewals)

I certify that the above-named individual was assigned the experienced educator named below to guide and assist while serving on the emergency permit.

________________________________________

Name of Experienced Educator

Employing Agency Signature

______________________________ _____________________________ _____________________________

Name of Authorized SignerTitleEmploying Agency

______________________________ _____________________________ _____________________________

Signature

Date

County of Employment

CL-469 CLAD-BCLAD 5/09

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PART II - Verification of Completion of Course Work or Exams

If t he applicant is complet ing course work in an approved CT EL program:

All of Part I (on page 1) must be completed by the employing agency. All sections of Part II (on page 2) must be completed by the authorized person in the credentials department at the college or university; however, Section A is only required with the first renewal, verifying that an evaluation of remaining credential requirements has been completed. There is no appeal available for this requirement not being completed. Sections B and C must be completed with every renewal. Return this original form to the applicant so it may be submitted with the renewal application packet.

If t he applicant is t aking examinat ions t o earn t he CLAD or BCLAD Cert if icat e:

All of Part I (on page 1) and Sections B and C of Part II (on page 2) must be completed by the employing agency with every renewal. Include the original copy of this form in the renewal application packet.

SECTION A

Required for the first renewal only for those completing course work in a Commission-approved CTEL program. To be verified by the college or university.

Yes No

An evaluation has been completed by this institution identifying requirements this applicant must complete to be eligible for the CLAD or BCLAD Certificate

SECTION B

Select one – required for all renewals

SECTION C

This signature block must be completed by the college or university if boxes 2 or 3 have been selected above. If box 1 has been selected, this signature block must be completed by the employing agency.

Authorized Signature

________________________________ _______________________________		_______________________________
Name of Authorized Signer	Title	IHE/Employing Agency
________________________________ _______________________________
Authorized Signature	Date

CL-469 CLAD-BCLAD 5/09

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