Act 48 Request Form

Act 48 Request Form
Credit Courses
Act 48 / Act 45 (PIL) Submission Information
_____________________________________________________________________________________
Last Name
First Name
MI or Former Last Name
_________________________________________________________________________________________________________________
Address
City
State
Zip Code
____________________________________
Phone Number
_____________________________________
SSN or PPI (required for submission)
_________________________________
Email Address
Current Pennsylvania Certification: _________________________________________________________________________________
Current Employer:
_________________________________________________________________________________________
Employer Address:
_________________________________________________________________________________________
Course Title
Semester Completed
Credits Earned*
Check if for PIL credit: 
Check if for PIL credit: 
Check if for PIL credit: 
Check if for PIL credit: 
Check if for PIL credit: 
Check if for PIL credit: 
* Final grade must be officially posted on Cal U student account before course information can be submitted to PDE for Act 48 or Act 45 credit.
_________________________________________________________
Participant’s Signature
Return completed forms to:
California University of PA
Office of Academic Affairs, Attn: Jodie Rooney
250 University Avenue, Box 4
California, PA 15419
Act 48 Submission Form – Fall 2010
_________________________________________________
Date
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