Connecticut Ed 170 Form – Fill Out and Use This PDF

ED 170	CONNECTICUT STATE DEPARTMENT OF EDUCATION
	Bureau of Educator Standards and Certification

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)

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.

(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

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

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.)