Fill - Free fillable RequestforPurchaseOrderFormforACSACredentialPROGRAMFees This is a request for a purchase (Association of California School Administrators) PDF form

2020 Association of California School Administrators/Foundation of Educational Administrators

EducationalSe

rvices*CredentialOffice*1029JStreet,Suite500

Sacramento,CA95814

RequestforPurchaseOrderFormforACSACredentialPROGRAMFees

This is a request for a purchase order, check, or credit card payment enrollment in the ACSA Clear

Administrative Credential Program (CACP) for the candidate listed below. This form indicates the employer

agrees to pay $1,000.00 each year of the two-year program for a total of $2,000.00. The first payment for

YEAR ONE is due December 15, 2020. The second payment for YEAR TWO is due December 15, 2021 and

no later than December 30, 2021. ThisrequestisforACSAClearAdministrativeCredentialProgramfeesonly.

ThereareadditionalfeesforACSAcredentialcoachingservicesdeterminedbyeachlocalprogram.

_____________________________________________________ ______________________________________________

Candidate Name Candidate Phone Number

PaymentInformationforACSACredentialProgramFeesYearOneandYearTwo

PurchaseOrder:

 Please provide a purchase order each year in the amount of $1,000.00

 Forward the purchase order to credentialing@acsa.org

 Make the purchase order payable to:

FEA or FoundationforEducationalAdministration

Check:

Mail:

• Please forward a check each year in the amount of $1,000 payable to:

FEA or FoundationforEducationalAdministration

• ACSA

Attn: Credential Office

1575 Bayshore Highway, Suite 300

Burlingame, CA 94010

ContactInformationforEmployerRepresentativeAuthorizedtoMakePayment

_____________________________________________________ ____________________________________________

Representative Name Authorized to Make Payment Representative’s Position

__________________________________________________________________ _______________________________________________________

District, County or LEA Name Representative Phone Number

__________________________________________________________________ _______________________________________________________

Representative Signature Representative E-mail

Retainacopyofthisformforyourrecordsandreference

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RequestforPurchaseOrderFormforACSACredentialPROGRAMFees This is a request for a purchase (Association of California School Administrators)

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