Connecticut Form Ed 192 – Fill Out and Use This PDF

ED 192	CONNECTICUT STATE DEPARTMENT OF EDUCATION
REV. 12/11	Bureau of Educator Standards and Certiication
C.G.S. 10-145f	P.O. Box 150471 – Room 243
	Hartford, CT 06115-0471
	www.ct.gov/sde

APPLICATION FOR CONNECTICUT ACADEMIC SKILLS ASSESSMENT WAIVER

The Connecticut Academic Skills Assessment Waiver Application will not be processed until this completed application and an OFFICIAL score report are received by the Bureau of Educator Standards and Certiication. (Scores sent by waiver candidates will NOT be accepted.) See Page 6 for application directions.

PERSONAL INFORMATION (Print all information in blue ink and in uppercase letters.)

Essential Skills Testing Requirement Waived Based Upon (Check one):

Refer to the Testing Agency Contact List (Page 3) for directions to have an oficial score report sent to the Con- necticut State Department of Education.

PAA Complete Page 4 in order to have an oficial PAA score report sent to the Connecticut State Department of Education.

PAGE 1

TESTING AGENCY CONTACT LIST

Scholastic Aptitude Test (SAT) Scores

The College Board maintains historical SAT scores on ile. Information about obtaining historical SAT results, including the score request form, is available online at: www.collegeboard.com/student/testing/ sat/scores/sending.html or call: 866-756-7346. The Program Code for the Connecticut State Depart-

ment of Education is 3132.

Mail your completed form to:

SAT Program

P.O. Box 8057

Mt. Vernon, IL 62864

American College Testing (ACT) Scores

The ACT maintains historical ACT scores on ile. Information about reporting historical ACT results, including the score request form, is available online at: www.actstudent.org/scores or call:

319-337-1313. The ACT Code for the Connecticut State Department of Education is 0625.

Mail your completed form to:

ACT Records

P.O. Box 451

Iowa City, IA 52243-0451

Graduate Record Examination (GRE) Scores

The Educational Testing Service (ETS) retains individual GRE test records for a period of ive years. If you have taken the GRE within the past ive years, please contact ETS online at: www.gre.org or call: 888-473-7267. Original reports must be ordered from ETS. Mail your completed form to ETS-ASR/ GRE, Box 371463, Pittsburgh, PA 15250-7463

.

Upon receipt forward the original score report to:

Bureau of Educator Standards and Certiication

Waiver Coordinator

P.O. Box 150471, Room 243

Hartford, CT 06115-0471

Candidates who took the GRE more than ive years ago must submit an oficial transcript showing their GRE scores, or an original document of the GRE score report sent to the candidate with the Connecticut Academic Skills Assessment Waiver Application form (ED 192).

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Connecticut State Department of Education

APPLICATION FOR CONNECTICUT ACADEMIC SKILLS ASSESSMENT WAIVER

Prueba de Aptitud Academica (PAA) Score Request

This form should be completed and mailed to the College Board in Puerto Rico ONLY if you received a total score on the PAA equivalent* to a score of 1000 on the Scholastic Aptitude Test (SAT), with neither the mathematics nor the verbal sub- test score below the equivalent of 400 points. Also, a minimum score of 510 on the English-as-a-Second-Language Achieve- ment Test (ESLAT) or the Test of English as a Foreign Language (TOEFL) is required.

I formally request that the College Board, Puerto Rico Ofice, forward my PAA scores to the Connecticut State Department of Education, Bureau of Educator Standards and Certiication.

PLEASE PRINT LEGIBLY AND PROVIDE AS MUCH INFORMATION AS POSSIBLE

The following information will facilitate this request.

Social Security Number:

Name at time of testing:

Date of Birth:

Current Name (If different from above):

Gender:

High School Attended:

Current Mailing Address:

Street:

City/Town:

State:

Zip:

Phone Number:

Date/Location of administration for which score report is requested:

Test Date:		Test Center:

Please mail my PAA score report to:

CONNECTICUT STATE DEPARTMENT OF EDUCATION

Bureau of Educator Standards and Certiication

Waiver Coordinator

P.O. Box 150471 - Room 243

Hartford, CT 06115-0471

Signature:		Date:

*Refer to Abbreviated Equivalency Table 1. Equivalent SAT scores are determined from an expanded table.

Important: Please contact the College Board for current information on fees for score reporting:

COLLEGE BOARD

Oicina de Puerto Rico y América Latina

P.O. Box 71101

San Juan, PR 00936-8001

Phone: 787-772-1200

Fax: 787-759-8629

E-mail: PROLAA@collegeboard.org

Website: http://oprla.collegeboard.com

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ED 192 – INSTRUCTIONS

REV. 12/11

C.G.S. 10-145f

HOW TO APPLY FOR A CONNECTICUT ACADEMIC SKILLS ASSESSMENT WAIVER

1.Complete form ED 192 – “Application For Connecticut Academic Skills Assessment Waiver.”

2.Mail Page 1 of the completed form (ED 192) to the address below.

3.Contact the respective testing company (SAT, ACT, GRE or PAA) and have your test scores reported to the Connecticut State Department of Education (CSDE). See contact list on Page 3. Test score re- ports forwarded to the CSDE from waiver applicants will only be accepted when a testing agency no longer has your scores on ile. Please note that it may take up to six weeks for the testing company to get your scores to the CSDE.

4.Upon receipt of your ED 192 and your SAT/ACT/GRE/PAA scores, you will be mailed written veri- ication of your Academic Skills Assessment Waiver.

If you have questions concerning the Connecticut Academic Skills Assessment Waiver, please write, phone, fax or email:

CONNECTICUT STATE DEPARTMENT OF EDUCATION

Bureau of Educator Standards and Certiication

Waiver Coordinator

P.O. Box 150471 – Room 243

Hartford, CT 06115-0471

Phone: 860-713-6969; Fax: 860-713-7017

Email: teacher.cert@ct.gov

Website: www.ct.gov/sde

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