Connecticut Ed 170 Form PDF Details

The Connecticut Ed 170 form serves as a cornerstone in the certification process for educators seeking to solidify their teaching credentials in the state. Organized by the Connecticut State Department of Education, specifically through the Bureau of Educator Standards and Certification, this form encompasses a broad array of critical information, including personal identification, academic background, and professional experience, to name a few. Prospective educators are required to disclose past convictions, dismissals, or any adverse actions related to professional licenses or certificates, ensuring a thorough vetting process in line with Connecticut General Statutes Sections 10-145 and 10-145d, as well as Public Act 03-168. A nonrefundable application fee, payable to the "Treasurer, State of CT," accompanies the form, emphasizing the seriousness and commitment required in pursuing educator certification. Additionally, the Ed 170 form outlines the diverse range of endorsements available, from early childhood education to specialized subjects for grades 7-12, reflecting the state's commitment to a comprehensive education system. This meticulous approach underscores the importance of integrity and excellence in Connecticut's education sector, aiming to foster a qualified, dedicated, and diverse teaching workforce.

QuestionAnswer
Form NameConnecticut Ed 170 Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesct application certificate form, ed general form, ct 170 form, connecticut 170

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ED 170

CONNECTICUT STATE DEPARTMENT OF EDUCATION

 

Bureau of Educator Standards and Certification

C.G.S. 10-145

C.G.S. 10-145d, P.A. 03-168

P.O. Box 150471

Hartford, CT 06115-0471

Enclose a NONREFUNDABLE application fee of $50 in the form of a money order,

cashier’s check or certified bank check payable to: “Treasurer, State of CT” (NO personal checks or cash accepted).

GENERALAPPLICATION FOR CERTIFICATE

LAST NAME

 

 

 

 

 

FIRST NAME

 

 

 

MI

GENDER

˗

˗

˗

˗

 

SOCIAL SECURITY NUMBER

BIRTH DATE (Month-Day-Year) - Required

ADDRESS (Street ONLY no P.O. Box)

 

 

 

Apt. #

(City)

 

 

 

 

(State)

 

˗

 

 

 

 

(Zip Code)

 

 

FORMER LAST NAME(S) Required

PHONE

˗

˗

 

 

 

 

 

 

 

 

 

 

 

(Home/Cell)

˗˗

(Work)

E-MAIL ADDRESS

1.Have you ever been convicted of any crime, excluding minor traffic violations?

2.Have you been dismissed for cause from any position?

3.Have you ever surrendered a professional certificate, license, permit or other credential (including, but not limited to, an education credential); had one revoked, suspended, annulled, invalidated, rejected or denied for cause; or been the subject of any other adverse or disciplinary credential action?

Race/Ethnicity

1.

Native American

 

2.

Asian/Pacific Islander

(Optional)

3.

Black

4.

White

 

5.

Hispanic

YES NO

YES NO

YES NO

Pursuant to Connecticut General Statutes Section 10-221d, the State Board of Education must submit, periodically, a database of applicants for an initial issuance of a certificate, authorization or permit to the State Police Bureau of Investigation for a criminal history record check. Each applicant seeking an initial issuance or renewal of a certificate, authorization or permit must also submit to a records check of the Department of Children and Families’ child abuse and neglect registry established pursuant to Connecticut General Statutes Section

17a-101k. In addition, the State Board of Education is required to submit periodically for criminal history records check the database of all persons who hold any certificate, authorization or permit.

NOTE: If you answer “YES” to any of the above questions, you must attach a signed statement of explanation. If there are multiple incidents within each question, you must list and explain each separately. Submit official copies of court or administrative record(s), including disposition of each use.

ED 170

(See enclosed code list.)

ENDORSEMENT #1 ENDORSEMENT #2 ENDORSEMENT #3 ENDORSEMENT #4

Check box if bilingual endorsement is sought for above discipline(s).

If requesting endorsement 090, 098, please indicate the specific occupational/vocational area (e.g., carpentry)

LIST THE NAMES OF COLLEGES OR UNIVERSITIES ATTENDED

 

 

 

Name of Institution

State

Major Field

Year of

College Credit or

 

 

 

of Study

Graduation

Degree Awarded

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please provide your education and work (within the last ten years) history, starting with your most recent position. Do not include student teaching, substitute or paraprofessional experience. Attach an additional sheet of paper, if needed.

NAME OF SCHOOL

LOCATION (City, State)

JOB TITLE

SUBJECT/FIELD

GRADE(S)

DATES EMPLOYED

FROM (M/Y) TO (M/Y)

(specify state and type of certificate)

(Attach a copy of both sides of out-of-state certificates, covering any of the experiences listed above that are within the last 10 years.)

I certify that the information provided by me on this application and any accompanying documents contains no material misrepresentations, falsifications or omissions and that all of the information given by me is true, complete and accurate. I understand that all application and accompanying information may be verified and that any material misrepresentation, falsification or omission may result in the denial or revocation of my certificate(s), permit(s) or authorization(s).

ORIGINAL SIGNATURE OF APPLICANT:

DATE:

Information on this application is subject to disclosure pursuant to the Freedom of Information Act.

ED 170

010Business, 7–12

015English, 7–12

018French, 7–12

019German, 7–12

020Italian, 7–12

021Latin, 7–12

022Russian, 7–12

023Spanish, 7–12

024Other World Language, 7–12

026History & Social Studies, 7–12

029Mathematics, 7–12

030Biology, 7–12

031Chemistry, 7–12

032Physics, 7–12

033Earth Science, 7–12

034General Science, 7–12

035 Driver Education

040 Agriculture, Pre-K–12

041Vocational Agriculture, 7–12

042Art, PK–12

043Health, PK–12

044Physical Education, PK–12

045Home Economics, PK–12

047Technology Education, PK–12

049Music, PK–12

055Partially Sighted, PK–12

057Deaf and Hard of Hearing, PK–12

059Blind, PK–12

062School Library Media Specialist

072 School Nurse-Teacher

073School Dental Hygienist-Teacher

089Marketing Education, 7–12

101World Language Instructor, Elementary

102Remedial Reading & Remedial Language Arts, 1–12

104Cooperative Work Education/Diversified Occupations

110Unique Subject-Area

111Teaching English to Speakers of Other Languages (TESOL), PK–12

112Integrated Early Childhood/Special Ed., Birth – Kindergarten

113Integrated Early Childhood/Special Ed., Nursery -K–Elem. 1–3

165Comprehensive Special Education, K–12

215English, Middle School

226History & Social Studies, Middle School

229Mathematics, Middle School

230Biology, Middle School

231Chemistry, Middle School

232Physics, Middle School

233Earth Science, Middle School

234General Science, Middle School

235Integrated Science, Middle School

305Elementary, 1–6

317Portuguese, 7–12

318Mandarin Chinese, 7–12

483Dance, Pre-K–12

485Theatre and Drama, Pre-K–12

511Montesori, Elementary, 1–6

512Montesori, Primary, Birth to Kindergarten

826Vocational Department Head: Trade Technology

085

School Business Administrator

088

Non-English Speaking Adults

092

Intermediate Administration or Supervision

106

High School Credit Diploma Program

093

Superintendent of Schools

107

External Diploma Program/Noncredit Mandated Programs

097Reading and Language Arts Consultant

105Department Chairperson

061

Speech and Language Pathologist

082

Vocational Technical Administrator

068

School Counselor

090

Occupational Subject, Vocational Technical Schools

070

School Psychologist

091

Trade-Related Subjects, Vocational Technical Schools

071

School Social Worker

098

Trade & Industrial Occupations – Comprehensive High School

268

School Marriage & Family Therapist

103

Health Occupations – Comprehensive High School

 

 

108

Practical Nurse Education Instruction

 

 

109

Health Occupations – Vocational Technical Schools

 

 

 

 

001

Pre-K–Grade 8

053

Physically Handicapped, 1–12

002

Pre-K–Grade 6

054

Physically Handicapped, 7–12

003

Pre-K–Grade 3

056

Partially Sighted, 7–12

004

Grades 1–8

058

Deaf, 7–12

005

Elementary Education, 1–6

060

Blind, 7–12

006

Middle Grades, 4–8

063

Special Teacher of Reading, 1–8

007

Academic Subjects

064

Special Teacher of Reading, 7–12

008

Pre-K and Kindergarten

065

Comprehensive Special Education, PK–12

009

Bilingual, PK–12

066

Guidance Counselor – Elementary

011

Licensed Practical Nurse

067

Guidance Counselor – Secondary

013

Elementary, K–6

069

Psychological Examiner

016

English, 7–9

074

Elementary Principal

017

Speech, 7–12

075

General Supervisor – Elementary

025

History, 7–12

076

Secondary Principal

027

Social Studies, 7–12

077

General Supervisor – Secondary

028

History & Social Studies, 7–9

078

Principal – Combined School

036

Core Curriculum

079

Special Supervisor

037

Psychology, 7–12

080

Administrative Assistant

038

Sociology, 7–12

081

Superintendent of Schools

039

Secondary Subject

083

Special Administrative

046

Vocational Home Economics, PK–12

086

Director of Adult Education (Full Time)

048

Librarian, 7–12

087

Director of Adult Education (Part Time)

050

Special Subject

094

Adult Education

051

Mentally Handicapped 1–12

095

Education Supervisor (State Department) 096

052

Mentally Handicapped 7–12

265

Comprehensive Special Education, 1–12

ED 170

CONNECTICUT STATE DEPARTMENT OF EDUCATION

 

Bureau of Educator Standards and Certification

C.G.S. 10-145

C.G.S. 10-145d, P.A. 03-168

P.O. Box 150471

Hartford, CT 06115-0471

INSTRUCTIONS FOR GENERALAPPLICATION FOR CERTIFICATION

continuation of a Connecticut Professional Educator Certificate (please use Form ED 179); or

renewal of an Initial Educator Certificate (please use Form ED 183).

complete and sign application;

submit $50 nonrefundable application fee;

submit official transcript(s); e-transcripts should be submitted directly by the college(s)/university to teacher.etranscript@ct.gov (submission of e-transcripts will expedite processing time);

submit ED-125 Statement of Preparing Higher Education Institution; and/or

submit ED-126 Statement of Professional Experience and copy of out-of-state certificate/license for applicants with prior teaching experience.

complete and sign application;

submit $250 (includes nonrefundable $50 application fee); and

submit ED-126 Statement of Professional Experience verifying a minimum of 10 months of full-time successful service in a Connecticut public school.

complete and sign application;

submit $375 (includes nonrefundable $50 application fee);

submit official transcript(s) verifying additional required coursework; e-transcripts submitted directly by the college(s)/university to teacher.etranscript@ct.gov (submission of e-transcripts will expedite processing time); and

submit ED-126 Statement of Professional Experience verifying 30 months of successful service under a Connecticut Provisional Certificate for a Connecticut board of education or in an approved nonpublic school.

complete and sign application;

submit certification fee of $50 (total fee is $100 per cross endorsement);

submit official transcript(s) for coursework applicable to cross endorsement requested and not submitted since 2009; e-transcripts submitted directly by the college(s)/university to teacher.etranscript@ct.gov (submission of e-transcripts will expedite processing time); and

verify successful completion of applicable testing requirements.

complete and sign application;

submit $50 application fee (additional $50 fee due upon qualification); and

submit official transcript(s); e-transcripts should be submitted directly by the college(s) to teacher.etranscript@ct.gov (submission of e-transcripts will expedite processing time).

An application will not be processed without the $50 certified bank check or money order. (No personal checks or cash accepted.)

The Bureau of Educator Standards and Certification will notify you by e-mail if additional credentials are required. Ensure you have provided a current, accurate e-mail address.

Retain a photocopy of all application materials for your records.

E-mail: teacher.cert@ct.gov

Website: www.ct.gov/sde/cert

Fax: 860-713-7017

Phone: 860-713-6969 24-hour automated phone line on Monday and Thursday, between 12-4 p.m.

(To speak with a staff member anytime during the greeting, press zero two times.)