41 4 Form PDF Details

The intricacies of the California Commission on Teacher Credentialing's Form 41-4, titled "APPLICATION FOR CREDENTIAL AUTHORIZING PUBLIC SCHOOL SERVICE," epitomize the rigorous and multifaceted process of credentialing educators and school service professionals in the state. Intended for varied purposes such as applying for new credentials, extending or upgrading existing ones, or even appealing for specific credential modifications, this comprehensive form serves as a critical pathway for educators to formalize their qualifications. Applicants are required to provide detailed personal information, select the specific type of credential they seek, and define the authorization or subject areas they are trained to teach. Beyond basic qualifications, the form also delves into professional growth activities for those renewing child development permits, ensuring educators continue to evolve in their roles. Critical to the integrity of the education system, the form addresses professional fitness questions aimed at safeguarding the school environment by evaluating the applicant's legal and professional history. Moreover, it underscores the responsibility of educators as mandated reporters of child abuse and neglect, embedding this statutory duty within the credentialing process. The form's thorough nature indicates the California Commission on Teacher Credentialing's commitment to maintaining high educational standards, embodying a diligent approach to certifying educators’ readiness to foster learning and development in California's diverse student population.

QuestionAnswer
Form Name41 4 Form
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namescredential 4 form, application subject permit get, form 41 4, 41 4 application form

Form Preview Example

 

 

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

 

 

 

 

 

 

 

 

 

 

 

*Social Security or Individual Tax Identification Number:

*Date of Birth: (mm/dd/yyyy)

 

*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

 

 

 

 

________________

 

 

New Credential/Permit

 

Extension by Appeal

 

Upgrade (Clear Credential or Child Development Permit)

 

 

 

Change of Restriction

 

Other:

 

 

Add Subject/Authorization to Existing Document

 

 

 

 

 

 

 

 

 

Renewal

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)

Multiple Subject (Elementary Teaching) Single Subject (Secondary Teaching):

(Specify World Language-if applicable)

Special Education Specialty Areas:

CTE Industry Sector:

English Learner Authorization

CLAD Certificate

Bilingual Authorization:

(Specify Language)

____________________________

Pupil Personnel Services:

Supplementary Authorization/ Subject Matter Authorization:

CTC Use Only

Adult Education Subjects:

FORM 41-4 (REV. 5/2021)

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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?

Yes

No

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)

Yes

No

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?

Yes

No

d. Are any criminal charges currently pending against you?

Yes

No

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?

Yes

No

FORM 41-4 (REV. 5/2021)

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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?

Yes

No

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)

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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)

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This PDF form will require particular info to be typed in, thus you need to take some time to enter what is required:

1. The application subject specify necessitates particular details to be entered. Ensure that the next blanks are finalized:

Part no. 1 of completing ctc form 41 4

2. When this section is completed, go to type in the applicable information in all these: New CredentialPermit, Extension by Appeal, Upgrade Clear Credential or Child, Renewal, Add SubjectAuthorization to, Change of Restriction, Other, CHOOSE DOCUMENT TYPE make only, TEACHING CREDENTIALS, SERVICES CREDENTIALS, EMERGENCY PERMITS, SUBSTITUTE PERMITS, CHILD DEVELOPMENT, Single Subject Multiple Subject, and Administrative Pupil Personnel.

How to complete ctc form 41 4 portion 2

3. In this stage, check out Special Education Specialty Areas, English Learner Authorization CLAD, Pupil Personnel Services, CTC Use Only, CTE Industry Sector, Adult Education Subjects, and FORM REV . These are required to be filled out with utmost accuracy.

Completing section 3 of ctc form 41 4

It is easy to get it wrong when completing the Adult Education Subjects, thus ensure that you look again prior to deciding to finalize the form.

4. This section comes next with these particular form blanks to complete: DECLARATION I certify or declare, I have completed, hours of professional growth, My Professional Growth Advisor is, Advisors Name, Advisors Phone Number, PROFESSIONAL FITNESS QUESTIONS, Answers to the following questions, Before granting your application, Federal Bureau of Investigation, You must disclose misconduct even, and It happened a long time ago It.

Stage number 4 of filling in ctc form 41 4

5. While you come close to the completion of your file, you'll notice just a few extra points to complete. Particularly, because of allegations of, Yes, b Have you ever been convicted of, You must disclose, all criminal convictions, misdemeanors and felonies , convictions based on a plea of no, convictions dismissed pursuant to, driving under the influence DUI or, no matter how much time has passed, You do not have to disclose, misdemeanor marijuanarelated, convictions involving concentrated, and infractions DUI or reckless should all be filled out.

The right way to fill out ctc form 41 4 step 5

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