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	ED 174	CONNECTICUT STATE DEPARTMENT OF EDUCATION
	REV. 1/12	Bureau of Educator Standards and Certiication
	C.G.S. 10-145, P.A. 11-27	P.O. Box 150471 – Room 243
	C.G.S. 10-145d	P.O. Box 150471 – Room 243
	C.G.S. 10-145d	Hartford, CT 06115-0471
	Regs. 10-145d-420	Hartford, CT 06115-0471
		www.ct.gov/sde

APPLICATION FOR SUBSTITUTE TEACHER AUTHORIZATION

FOR CANDIDATES WHO HAVE NOT COMPLETED A BACHELOR’S DEGREE

PART I: PERSONAL INFORMATION (Print all information in dark ink and in uppercase letters.)

LAST NAME

FIRST NAME

GENDER (M/F)

–

SOCIAL SECURITY NUMBER

BIRTH DATE (Month-Day-Year) – Required

ADDRESS (Street)

(Apt #)

(City)

–

FORMER LAST NAME(S)

(State)

(Zip Code)

PHONE

–

Race/Ethnicity

Native American

(Home/Cell)

Asian/Paciic Islander

E-MAIL ADDRESS

Black

(Optional)

White

Hispanic

Have you ever been convicted of any crime, excluding minor trafic violations?

YES

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

YES

Have you ever surrendered a professional certiicate, license, permit or other credential

YES

(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?

Pursuant to Connecticut General Statutes Section 10-221d, the State Board of Education must complete a criminal history records check on each applicant for an initial issuance or renewal of a certiicate, authorization or permit. Each applicant seeking an initial issuance or renewal of a certiicate, 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 a criminal history records check the database of all persons who hold any certiicate, 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 oficial copies of court or adminis- trative record(s), including disposition of each case.

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

PAGE 1

ED 174

PART II: EDUCATIONAL BACKGROUND

List all education you have completed, including high school, trade-related vocational school and/or other postsecondary schooling.

NAME OF SCHOOL

STATE DATES ATTENDED

From (M/Y) To (M/Y)

EDUCATION LEVEL COMPLETED

(H.S. Diploma, GED, Assoc. Degree)

List ALL substitute teaching experience or any other experiences you have had working with school-age children, along with any unique qualiications for the substitute position. (Please attach your resume, or a separate sheet, if necessary.)

PART III: APPLICANT ATTESTATION

I certify that the information provided by me on this application and any accompanying documents contains no material misrepresentations, falsiications 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 veriied and that any material misrepresentation, falsiication or omission may result in the denial or revocation of my certiicate(s), permit(s) or authorization(s).

ORIGINAL SIGNATURE OF APPLICANT

DATE:

PART IV: EMPLOYING AGENT INFORMATION AND ATTESTATION

The applicant will serve only as a substitute teacher in random assignments and only up to 40 days in one assignment.

Signature of Superintendent, Executive Director or designee attesting to the accuracy of information

(Original Signature: No Signature Stamps Accepted)

Typed or Printed Name of Person Signing Above

District

Street

City,

State, Zip Code

FOR OFFICE USE ONLY

The person named on this application is authorized of education listed above.

Authorized Signature:

Date

Title

Telephone

FAX Number

E-mail Address

is NOT authorized to serve as a substitute teacher for the board

Date:

Original Signatures Must Be On Form Submitted

PAGE 2

ED 174	CONNECTICUT STATE DEPARTMENT OF EDUCATION
REV. 1/12	Bureau of Educator Standards and Certiication
REV. 1/12
C.G.S. 10-145, P.A. 11-27	P.O. Box 150471 – Room 243
C.G.S. 10-145d	P.O. Box 150471 – Room 243
Regs. 10-145d-420	Hartford, CT 06115-0471
	Hartford, CT 06115-0471
	www.ct.gov/sde

INSTRUCTIONS TO APPLICATION FOR SUBSTITUTE TEACHER AUTHORIZATION

FOR CANDIDATES WHO HAVE NOT COMPLETED A BACHELOR’S DEGREE

THIS CHECKLIST MUST BE ATTACHED TO THE COMPLETE APPLICATION PACKET

Listed below are the required documents which must be submitted to the Bureau of Educator Standards and Certi- ication to process your request for a Substitute Teacher Authorization for candidates who have NOT completed a bachelor’s degree. This authorization will expire on June 30 of the school year during which it was approved.

Applicant:

a. Complete Parts I, II and III.

b. Return completed application to the superintendent of schools, executive director or designee.

Employing Agent:

a. Complete Part IV and mail application and supporting documentation to the Bureau of Educator Standards and Certiication at the above address.

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

Question	Answer
Form Name	Connecticut Form Ed 174
Form Length	3 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	45 sec
Other names	ed_174 ct sde 174 form

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