Hemet Unified School District

1791 W. Acacia Avenue Hemet, CA 92545 Certificated Transfer Request Form Phone (951) 765-5100

I request a voluntary transfer:

LAST NAME, FIRST NAME EMAIL ADDRESS

CELL PHONE NUMBER WORK PHONE

(current assignment(s) (current location(s)

(requested assignment(s) (requested location(s)

CREDENTIALS HELD:

TYPE: EXPIRES:

PROFESSIONAL REFERENCES (Include only those who have knowledge of your teaching experience, i.e., administrators, supervisors, etc.) Name Position Telephone Number

TO BE COMPLETED BY HUMAN RESOURCES ONLY NCLB INFORMATION CREDENTIAL INFORMATION NOTES NCLB COMPLIANT IN CURRENT HOLDS PROPER CREDENTIAL FOR DATE RECEIVED ASSIGNMENT: YES NO CURRENT ASSIGNMENT: YES NO NCLB COMPLIANT IN REQUESTED HOLDS PROPER CREDENTIAL FOR ASSIGNMENT: YES NO REQUESTED ASSIGNMENT: YES NO NCLB NOTES: BOARD AUTHORIZATION REQUIRED VALID FOR SCHOOL YEAR: YES NO ______1791 W. Acacia Avenue Hemet, CA 92545 Certificated Transfer Request Form Phone (951) 765-5100

COLLEGE OR UNIVERSITY EDUCATION Name & Location of each Attended Graduated Major(s) Minor(s) College or University From To Date Degree

TEACHING EXPERIENCE (List most recent assignment first) Dates # of Private Assignment Subjects School District From To Mnths or Public

TOTAL YEARS OF TEACHING

Signature of Applicant Date Revised 5/8/2012ml