2020 Association of California School Administrators/Foundation of Educational Administrators
EducationalSe
rvices*CredentialOffice*1029JStreet,Suite500
Sacramento,CA95814
RequestforPurchaseOrderFormforACSACredentialPROGRAMFees
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. ThisrequestisforACSAClearAdministrativeCredentialProgramfeesonly.
ThereareadditionalfeesforACSAcredentialcoachingservicesdeterminedbyeachlocalprogram.
_____________________________________________________ ______________________________________________
Candidate Name Candidate Phone Number
PaymentInformationforACSACredentialProgramFeesYearOneandYearTwo
PurchaseOrder:
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 FoundationforEducationalAdministration
Check:
Mail:
Please forward a check each year in the amount of $1,000 payable to:
FEA or FoundationforEducationalAdministration
ACSA
Attn: Credential Office
1575 Bayshore Highway, Suite 300
Burlingame, CA 94010
ContactInformationforEmployerRepresentativeAuthorizedtoMakePayment
_____________________________________________________ ____________________________________________
Representative Name Authorized to Make Payment Representative’s Position
__________________________________________________________________ _______________________________________________________
District, County or LEA Name Representative Phone Number
__________________________________________________________________ _______________________________________________________
Representative Signature Representative E-mail
Retainacopyofthisformforyourrecordsandreference