The Connecticut State Department of Education provides a crucial pathway for educators looking to continue their journey in teaching through the ED 179 form, a comprehensive application for the continuation of a Professional Educator Certificate. This form, revised as of March 2013, adheres to the standards and certifications outlined by the Bureau of Educator Standards and Certification under legislative acts including C.G.S. 10-145b as amended by PA 12-116. Applicants are required to submit personal information in a specific manner, highlighting the department's attention to detail and the importance of accuracy in the application process. Part I of the form not only gathers basic personal information but also addresses critical questions concerning any criminal convictions, dismissals for cause, or any adverse actions related to professional credentials, thus ensuring that the educators serving Connecticut's learners meet the highest standards of integrity and professionalism. Furthermore, Part II delves into the applicant's professional experience, requiring detailed documentation of service under the current Professional Educator Certificate. This section underscores the value of sustained, quality education experiences for students by verifying the applicant's teaching engagements. By completing the ED 179 form, educators affirm their commitment to maintaining the rigorous standards set forth by the Connecticut State Department of Education, all the while contributing to a safe, effective, and inspiring learning environment for students across the state.
| Question | Answer |
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| Form Name | Form Ed 179 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | ed_179 connecticut application for continuation professional educator certificate online form |
ED 179 |
CONNECTICUT STATE DEPARTMENT OF EDUCATION |
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REV. 3/13 |
Bureau of Educator Standards and Certiication |
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C.G.S. |
P.O. Box 150471 – Room 243 |
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as amended by PA |
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Hartford, CT |
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Sec. 36 |
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www.ct.gov/sde/cert |
APPLICATION FOR CONTINUATION OF PROFESSIONAL EDUCATOR CERTIFICATE
PART I: PERSONAL INFORMATION (Print all information in blue ink and in uppercase letters.)
LAST NAME
FIRST NAME
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SOCIAL SECURITY NUMBER
ADDRESS (Street)
(City) |
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(State) |
(Zip Code) |
PHONE |
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(Home) |
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(Work) |
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MI |
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GENDER (M/F) |
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BIRTH DATE
(Apt #)
FORMER LAST NAME(S)
Race/Ethnicity 1. Native American
2.Asian/Paciic Islander
3.Black
(Optional) 4. White
5. Hispanic
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1. |
Have you ever been convicted of any crime, excluding minor trafic violations? |
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YES |
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Have you ever been dismissed for cause from any position? |
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YES |
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Have you ever surrendered a professional certiicate, license, permit or other credential |
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YES |
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(including, but not limited to, an education credential); had one revoked, suspended, |
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annulled, invalidated, rejected or denied for cause; or been the subject of any other |
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adverse or disciplinary credential action? |
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NO NO NO
Pursuant to Connecticut General Statutes Section
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.
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ED 179
PART II: STATEMENTS OF PROFESSIONAL EXPERIENCE
Check the appropriate box to indicate service under your current Professional Educator Certiicate.
A.
B.
I have not served under my current Professional Educator Certiicate for a Board of Education.*
I have served under my current Professional Educator Certiicate in the following positions for a Connecticut Board
of Education.
If you checked “B,” please complete the Grid below. Also, please submit form ED 126 signed by the superintendent, documenting experience under your current Professional Educator Certiicate. A separate form ED 126 must be submitted for each district in which you were employed under this Professional Educator Certiicate.
Form ED 126 is available at www.ct.gov/sde/certapps.
Employing |
Position Held |
Grade |
Certiication |
Check Below if: |
Dates of Service |
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District |
(e.g., teacher, |
Level |
Endorsement |
Full- |
Part- |
From |
To |
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administrator, social |
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Required for |
Time |
Time |
(Month/ |
(Month/ |
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worker, substitute) |
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Position |
(50% or |
(less |
Year) |
Year) |
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more) |
than |
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50%) |
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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:
*Board of Education means a Connecticut local or regional Board of Education, regional educational service center, uniied school district, cooperative arrangement established pursuant to
Original Signatures Must Be On Form Submitted
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