California Proficiency Contact Designation Request

California Proficiency Contact Designation Request

Superintendents or authorized administrators must use this form to designate an alternate contact to receive quarterly student passing rosters for the California Proficiency Program. If any changes or updates are needed for the alternate contact, this form must be resubmitted.

Local Educational Agency (LEA)/Independent Charter School

LEA Name *

CDS Code *

Superintendent/Charter School Administrator Information

Name*

Title *

Email Address*

Phone Number*

Street Address *

City*

Zip Code*

Designated Contact Information

Designated Contact Name *

Designated Contact Title *

Designated Contact Email *

Designated Contact Phone Number *

Designated Contact Street Address *

Designated Contact City *

Designated Contact Zip Code *

Electronic Certification*

I affirm that the designated contact listed above is authorized to receive quarterly student passing rosters for the California Proficiency Program. I understand that this individual will serve as the primary recipient for this data, and I will ensure that any future changes to this contact are promptly updated by resubmitting this form.

Date of Submission*

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