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Alternative Licensure Program Application

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

San Juan College email address *

San Juan College ID Number *

Personal email address *

Which of the following best describes your race or ethnicity? (Check all that apply) This information is helpful for our program and also lets us know if you qualify for grant funding to assist you in your education. *

Where did you hear about ALP? *

Which ALP Licensure Track are you pursuing? Please select only one option. *

Elementary (K-8)

Secondary (7-12)

Special Education (Elementary: K - 8)

Special Education (Secondary: 7 - 12)

Degree Awarded (i.e. B.S. Chemistry) *

Earned degree from which college or university? *

Month & year of degree earned (i.e. May 2005)? *

Each college/university attended:

+-

Do you have a contracted position? *

Which school district? What grade level? What subject? *