ED 170: General Application for Certificate

Print all information in blue ink and in uppercase letters.

Enter LAST NAME, FIRST NAME, MI, GENDER, SOCIAL SECURITY NUMBER and BIRTH DATE (Month-Day-Year).

Enter the ADDRESS (Street ONLY no P.O. Box) and Apt. #.

Enter (City), (State) and (Zip Code), then FORMER LAST NAME(S) Required.

Enter PHONE (Home/Cell) and (Work).

Under Race/Ethnicity, enter 1. Native American, 2. Asian/Pacific Islander, 3. Black, 4. White or 5. Hispanic.

Enter the E-MAIL ADDRESS (Required).

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.

Have you ever been convicted of any crime, excluding minor traffic violations? Mark YES or NO.

Have you been dismissed for cause from any position? Mark YES or NO.

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? Mark YES or NO.

If you answer “YES” to any of these 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.

In PART II, list the CERTIFICATION ENDORSEMENTS REQUESTED (See enclosed code list.) as ENDORSEMENT #1, ENDORSEMENT #2, ENDORSEMENT #3 and ENDORSEMENT #4. Check box if bilingual endorsement is sought for the discipline(s) in PART II.

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

In PART III: EDUCATIONAL BACKGROUND, list the names of colleges or universities attended, with Name of Institution, State, Major Field of Study, Year of Graduation and College Credit or 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.

Enter NAME OF SCHOOL, LOCATION (City, State), JOB TITLE, SUBJECT/FIELD, GRADE(S) and DATES EMPLOYED FROM (M/Y) TO (M/Y).

PART V: DO YOU HOLD/HAVE YOU HELD AN OUT-OF-STATE CERTIFICATE? Mark YES or NO (specify state and type of certificate). Attach a copy of both sides of out-of-state certificates, covering any of the experiences listed in PART IV that are within the last 10 years.

In PART VII: APPLICANT ATTESTATION, by signing you certify that the information provided by you on this application and any accompanying documents contains no material misrepresentations, falsifications or omissions and that all of the information given by you is true, complete and accurate. You 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 your certificate(s), permit(s) or authorization(s).

For First-Time Applicants (Initial Educator Certificate), submit official transcript(s) via U.S. mail; e-transcripts must be submitted directly by the college(s)/university to: teacher.etranscript@ct.gov;

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.

For Advancement to a Professional Educator Certificate, submit payment of $375 in the form of a money order, cashier's check, or certified bank check payable to “Treasurer, State of Connecticut,” or payment may be made online via credit card (checked November 8, 2026). Personal checks are not accepted.

Submit official transcript(s) via U.S. mail verifying additional required coursework; e-transcripts must be submitted directly by the college(s)/university to teacher.etranscript@ct.gov; and

Submit ED-126 Statement of Professional Experience verifying 50 months of successful service in a Connecticut public school or approved nonpublic school, under an Initial and/or Provisional Certificate.

For Cross Endorsement if You Hold a Connecticut Teacher Certificate, submit payment of $100 (per endorsement) in the form of a money order, cashier's check, or certified bank check payable to “Treasurer, State of Connecticut,” or payment may be made online via credit card (checked November 8, 2026). Personal checks are not accepted.

Submit official transcript(s) for coursework applicable to endorsement sought; and verify successful completion of applicable testing requirements.

For Advancement of an Adult Education Certificate to the Professional Level, submit payment of $100 in the form of a money order, cashier's check, or certified bank check payable to “Treasurer, State of Connecticut,” or payment may be made online via credit card (checked November 8, 2026). Personal checks are not accepted.

Submit official transcript(s) via U.S. mail; e-transcripts must be submitted directly by the college(s) to teacher.etranscript@ct.gov; and

Submit ED-126 Statement of Professional Experience verifying 50 months of successful service teaching adult education in a Connecticut public school, under an Initial and/or Provisional Certificate.

Use this form for all requests EXCEPT renewal of a Connecticut Professional Educator Certificate (please use Form ED 179); or renewal of an Initial Educator Certificate (please use Form ED 183).