41 4 Form – Fill Out and Use This PDF

		APPLICATION FOR CREDENTIAL AUTHORIZING PUBLIC SCHOOL SERVICE
			(For Privacy Act Notification see Application Instructions)				Appeal:__________________
Mail application and payment
(check or money order) to:							Route to: ________________
Commission on Teacher Credentialing
Certification Division						IHE/County/District Use Only
1900 Capitol Avenue
Sacramento, California 95811-4213
	Commission Use Only: Fee Information					Issuance
	APP	FP	Other			Date:____________________________
						Email:____________________________
	1. PERSONAL INFORMATION (type or print)				CTC Use Only

	*My Full Legal Name: __________________________\_________________________\________________________________
		First		Middle					Last
	All Former/Maiden Name(s):			County/District of Employment (CA only):
								IHE/County/District Use
	*Address:							Only
	*City:				*State:				*Zip:
	Home Phone:		Work Phone:				Mobile Phone:
	*Email Address:							Issuance
								Date:__________________
	2. APPLICATION TYPE REQUESTED: (select only one option)								* = Required Information
								E-Mail Address:
		CCTC Use Only						________________

3.CHOOSE DOCUMENT TYPE: (make only one selection in this section)

*= Available at the request of a California Local Education Agency (LEA) only. Documents in bold font require you to select from Section 4 below a Subject or Authorized Area of Service to be listed on the document.

TEACHING CREDENTIALS:	SERVICES CREDENTIALS:		EMERGENCY PERMITS*:		SUBSTITUTE PERMITS:		CHILD DEVELOPMENT
Single Subject		Administrative		Limited Assignment*		30-Day Substitute	PERMITS:
Multiple Subject		Pupil Personnel		Short-Term Staff*		Career Substitute*			Assistant
Education Specialist		Speech-Language		Provisional Internship*		Prospective Substitute			Associate Teacher
Career Technical (CTE)		Pathology		EM CLAD*		Teaching Permit for			Teacher
						Statutory Leave*
Adult Education		Teacher Librarian		EM Bilingual*					Master Teacher
Other:		School Nurse		EM Teacher Librarian*		30-Day CTE Substitute			Site Supervisor
____________________		Other:		EM Resource Specialist*					Program Director
	__________________								Children's Center
									Permit
									School-Age
									Emphasis

4.SELECT AUTHORIZATION/SUBJECT AREA(S): (to choose additional subject areas, see page 5 “Comments” box)

Adult Education Subjects:

FORM 41-4 (REV. 5/2021)	1

5. CHILD DEVELOPMENT PERMIT RENEWAL SELF-VERIFICATION

As the holder of a Child Development Permit (any level except the Associate Teacher Permit) you must complete a specific number of planned and approved professional growth activities for each five-year renewal. These activities must be recorded on the Professional Growth Plan and Record form. As the holder of a Child Development Permit choosing to self-verify completion of these requirements, you may be subject to an audit. The Commission reserves the right to request submission of these forms for auditing purposes any time within one year following submission of this application. If the Commission determines through its audit that you did not complete the professional growth requirements, your permit will not be renewed and you may be subject to adverse action on other credentials you currently hold. You must retain your Professional Growth Plan and Record form for one year following the submission of this application.

DECLARATION:

I certify (or declare) that I have read the above and completed the following for this renewal of my Child Development Permit:

I have completed __________ hours of professional growth activities
My Professional Growth Advisor is ___________________________________________	____________________________
Advisor’s Name	Advisor’s Phone Number

6. PROFESSIONAL FITNESS QUESTIONS

Answers to the following questions are required. If you answer yes to any question, you must complete the

corresponding Professional Fitness Explanation Form.

Before granting your application, the Commission will review, at a minimum:

Federal Bureau of Investigation criminal history (rap sheet)

California Department of Justice criminal history (rap sheet)

International database of teacher misconduct maintained by the National Association of State Directors of Teacher Education and Certification (NASDTEC)

Previous reviews by the Commission

Complaints from others

Notifications from school districts

Teacher preparation test score violations

You must disclose misconduct, even if:

It happened a long time ago

It happened in another state, federal court, military or jurisdiction outside the United States

You did not go to court and your attorney went for you

You did not go to jail or the sentence was only a fine or probation

You received a certificate of rehabilitation

Your conviction was later dismissed (even if under Penal Code section 1203.4), expunged, set aside or the sentence was suspended

WARNING: You will be required to sign your application under penalty of perjury; by doing so you are also stating that you understand:

That the information you provide is true and correct;

That you understand any and all instructions related to your application;

Failure to disclose any information requested is falsification of your application and the Commission may reject or deny your application or take disciplinary action against your credential;

The Commission may reject your application if it is incomplete and it will be delayed.

FORM 41-4 (REV. 5/2021)	2

a.Have you ever been:

dismissed or,

non-reelected or,

suspended without pay for more than ten days, or

retired, or

resigned from, or otherwise left school employment

because of allegations of misconduct or while allegations of misconduct were pending?

b.Have you ever been convicted of any felony or misdemeanor in California or any other place? You must disclose:

all criminal convictions

misdemeanors and felonies

convictions based on a plea of no contest or nolo contendere

convictions dismissed pursuant to Penal Code Section 1203.4

driving under the influence (DUI) or reckless driving convictions

no matter how much time has passed

You do not have to disclose:

misdemeanor marijuana-related convictions that occurred more than two years prior to this application, except convictions involving concentrated cannabis, which must be disclosed regardless of the date of such a conviction.

infractions (DUI or reckless driving convictions are not infractions)

c.Are you currently the subject of any inquiry or investigation by any law enforcement agency or any licensing agency in California or any other state?

d. Are any criminal charges currently pending against you?

e.Have you ever had any credential, including but not limited to, any Certificate of Clearance, permit, credential, license or other document authorizing public school service, revoked, denied, suspended, publicly reproved, and/or otherwise subjected to any other disciplinary action (including an action that was stayed) in California or any other state or place?

FORM 41-4 (REV. 5/2021)	3

f.Have you ever had any professional or vocational (not teaching or educational) license revoked, denied, suspended, and/or otherwise subjected to any other disciplinary action (including an action that was stayed) in California or any other state or place?

7. CHILD ABUSE AND NEGLECT MANDATED REPORTING

As a documentholder authorized to work with children, it is part of my professional and ethical duty to report every instance of child abuse or neglect known or suspected to have occurred to a child with whom I have professional contact.

I understand that I must report immediately, or as soon as practicably possible, by telephone to a law enforcement agency or a child protective agency, and will send a written report and any evidence relating to the incident within 36 hours of becoming aware of the abuse or neglect of the child.

I understand that reporting the information regarding a case of possible child abuse or neglect to an employer, supervisor, school principal, school counselor, coworker, or other person is not a substitute for making a mandated report to a law enforcement agency or a child protective agency.

I understand that the reporting duties are individual and no supervisor or administrator may impede or inhibit my reporting duties.

I understand that once I submit a report, I am not required to disclose my identity to my employer.

I understand that my failure to report an instance of suspected child abuse or neglect as required by the Child Abuse and Neglect Reporting Act under Section 11166 of the Penal Code is a misdemeanor punishable by up to six months in jail or by a fine of one thousand dollars ($1,000), or by both that imprisonment and fine.

I acknowledge and certify that as a documentholder, I will fulfill all the duties required of a mandated reporter.

I agree

8. EMPLOYING AGENCY INFORMATION

This section must be completed for all credential, certificate, and permit types where service is restricted to an employing agency.

County CDS Code _________________________________ School District CDS Code ______________________________

Charter School/Non-Public School or Agency/Statewide Agency Name ____________________________________________

Applications for One-year Nonrenewable Credentials, Provisional Internship Permits, Short-Term Staff Permits, Limited Assignment Permits, and Emergency Permits (except 30-Day or Prospective Substitute Teaching Permits), must be filed through the employing agency. Employers must have an annual Declaration of Need for Fully Qualified Educators on file with the Commission prior to the submission of any applications for Limited Assignment or Emergency Permits.

Before submitting, please review the application for completeness:

1)Personal information with correct SSN, date of birth, and email address filled in on page 1

2)Type of credential clearly marked on page 1 (use box below for additional subject/authorization requests)

3)All Professional Fitness Questions marked Yes or No on pages 3 and 4

4)Read and agreed to your responsibilities as a mandated reporter

5)Payment (check or money order attached to the front of this form). See Credential Leaflet CL-659 for fee schedule.

FORM 41-4 (REV. 5/2021)	4

Checks or money orders may be made payable to the Commission on Teacher Credentialing. The Commission DOES NOT accept cash payments. All application fees are non-refundable.

Applications submitted that are incomplete or without the appropriate fee included will not be processed and will be returned.

9. OATH AND AFFIDAVIT *

I solemnly swear (or affirm) that I will support the Constitution of the United States of America, the Constitution of the State of California, and the laws of the United States and the State of California. I hereby certify (or declare) under penalty of perjury under the laws ofthe State of California that all the foregoing statements in this application are true and correct.

Date	_____________________		City	_________________________________________	County ___________________ State ________
	(mm/dd/yyyy)			(where you sign the form)

SIGNATURE OF APPLICANT __________________________________________________________________________________________

* You must complete all portions of this section.

Comments/Additional Subject Requests:

FORM 41-4 (REV. 5/2021)	5