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Request for Change in State Licensure Selection

Student Name

Email

Year of entry

Quarter of entry

Request to Initiate Fieldwork Submitted?

Degree program

Previously Selected State Licensure

Reason for requesting change to licensure

Note: Please include a brief paragraph addressed to the Student Development Committee. Additionally, if you are considering trying to get licensed in a state other than California and are hoping that Meridian’s curriculum can meet that state’s educational eligibility requirements, you are welcome to send us the text of that state’s regulations on this, for the faculty’s best ‘guesstimate’ of this.
Please check the box below to confirm your understanding that if the current licensure selection is removed from your graduation requirements:
1. The University will therefore no longer be ensuring that you complete the required licensure-related coursework, fieldwork or any other related items.
2. The University cannot in the future address licensing eligibility related issues.
3. The University will not be able to confirm upon your graduation whether your degree meets state licensure requirements.
Untitled checkboxes field

Signature

Signature

Date