<p> 1791 W. Acacia Avenue Hemet, CA 92545 Certificated Transfer Request Form Phone (951) 765-5100</p><p>I request a voluntary transfer:</p><p>LAST NAME, FIRST NAME EMAIL ADDRESS</p><p>CELL PHONE NUMBER WORK PHONE</p><p>FROM:</p><p>(current assignment(s) (current location(s)</p><p>TO:</p><p>(requested assignment(s) (requested location(s)</p><p>CREDENTIALS HELD:</p><p>TYPE: EXPIRES: </p><p>TYPE: EXPIRES: </p><p>PROFESSIONAL REFERENCES (Include only those who have knowledge of your teaching experience, i.e., administrators, supervisors, etc.) Name Position Telephone Number</p><p>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</p><p>COLLEGE OR UNIVERSITY EDUCATION Name & Location of each Attended Graduated Major(s) Minor(s) College or University From To Date Degree</p><p>TEACHING EXPERIENCE (List most recent assignment first) Dates # of Private Assignment Subjects School District From To Mnths or Public</p><p>TOTAL YEARS OF TEACHING </p><p>Signature of Applicant Date Revised 5/8/2012ml</p>