Form Ed 179 – Fill Out and Use This PDF

Form Ed 179 is an online collaborative platform designed to help cultivate an environment of learning and professional development. An intentional blend of digital instruction, social support and ongoing feedback creates a culture of ideas with the potential to benefit the schools, teachers, and students within our communities. Our core mission is to change and innovate teaching and learning methodology. Form Ed supports initiatives that consider multiples forms of educational content strengthening overall understanding by creating an interactive blended curriculum. Furthermore, educators can use this as a way to showcase their unique strengths within a field, firmly setting them on paths for both personal and career achievements.

Form Ed 179 PDF Details

Form Ed 179 is a form that employers use to report employee wages and deductions. The purpose of this form is to ensure that the employer withholds the correct amount of taxes from each employee's paycheck. This form must be filed with the IRS every quarter, and it is essential for businesses that have employees to submit this form accurately and on time. In this blog post, we will discuss how to complete Form Ed 179 correctly so that your business can stay in compliance with IRS tax regulations.

Question	Answer
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

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	ED 179	CONNECTICUT STATE DEPARTMENT OF EDUCATION
	REV. 3/13	Bureau of Educator Standards and Certiication
	C.G.S. 10-145 b	P.O. Box 150471 – Room 243
	as amended by PA 12-116,	P.O. Box 150471 – Room 243
	as amended by PA 12-116,	Hartford, CT 06115-0471
	Sec. 36	Hartford, CT 06115-0471
		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

– –

SOCIAL SECURITY NUMBER

ADDRESS (Street)

(City)
(State)	(Zip Code)
PHONE	–
	(Home)
	–
	(Work)

E-MAIL ADDRESS

–

MI				GENDER (M/F)
–				–
–				–

BIRTH DATE (Month-Day-Year) – Required

(Apt #)

FORMER LAST NAME(S)

Race/Ethnicity 1. Native American

2.Asian/Paciic Islander

3.Black

(Optional) 4. White

5. Hispanic


1.	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


3.	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?

NO NO NO

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 179

PART II: STATEMENTS OF PROFESSIONAL EXPERIENCE

Check the appropriate box to indicate service under your current Professional Educator Certiicate.

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
District	(e.g., teacher,	Level	Endorsement	Full-	Part-	From	To
	administrator, social		Required for	Time	Time	(Month/	(Month/
	worker, substitute)		Position	(50% or	(less	Year)	Year)
				more)	than
					50%)

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 10-158A of the Connecticut General Statutes, the Connecticut Technical High School System, approved private special education facilities, the Gilbert School, Norwich Free Academy or Woodstock Academy.

Original Signatures Must Be On Form Submitted

PAGE 2

Form Ed 179 – Fill Out and Use This PDF

Form Ed 179 PDF Details

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