Form ED170A "Short Form Application for Connecticut Initial Educator Certificate" - Connecticut

What Is Form ED170A?

This is a legal form that was released by the Connecticut State Department of Education - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2021;
  • The latest edition provided by the Connecticut State Department of Education;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form ED170A by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Education.

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Download Form ED170A "Short Form Application for Connecticut Initial Educator Certificate" - Connecticut

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ED 170A
CONNECTICUT STATE DEPARTMENT OF EDUCATION
REV. 5/21
Bureau of Educator Standards and Certification
C.G.S. 10-145
P.O. Box 150471
C.G.S. 10-145d, P.A.
Hartford, CT 06115-0471
Regs. 10-145d-412
www.ct.gov/sde/cert
SHORT FORM APPLICATION FOR CONNECTICUT INITIAL EDUCATOR CERTIFICATE
Submit $200 (includes $50 nonrefundable application fee) money order, cashier’s
check or certified bank check payable to: “Treasurer, State of CT” (NO personal checks or cash accepted).
PART I: PERSONAL INFORMATION (Print all information in blue ink and in uppercase letters.)
LAST NAME
FIRST NAME
MI
GENDER
˗
˗
˗
˗
BIRTH DATE (Month-Day-Year) - Required
SOCIAL SECURITY NUMBER
ADDRESS (Street ONLY no P.O. Box)
Apt. #
(City)
(State)
˗
FORMER LAST NAME(S) Required
(Zip Code)
˗
˗
PHONE
(Home/Cell)
Race/Ethnicity
1.
Native American
˗
˗
2.
Asian/Pacific Islander
(Work)
3.
Black
(Optional)
4.
White
BACHELOR’S DEGREE
5.
Hispanic
STATE/COUNTRY
DEGREE AWARDED
Mo./Yr.
E-MAIL ADDRESS
1.
Have you ever been convicted of any crime, excluding minor traffic violations?
YES
NO
2.
Have you been dismissed for cause from any position?
YES
NO
3.
Have you ever surrendered a professional certificate, license, permit or other credential
YES
NO
(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?
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 official copies of court or administrative record(s), including disposition of each case.
Pursuant to Connecticut General Statutes Section 10-221d, the State Board of Education must submit, periodically, a database of applicants for an initial
issuance of a certificate, authorization or permit to the State Police Bureau of Investigation for a criminal history record check. Each applicant seeking an
initial issuance or renewal of a certificate, 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 criminal history records check the database of all persons who hold any certificate, authorization or permit.
APPLICANT ATTESTATION: I certify that the information provided by me on this application and any accompanying documents contains no material
misrepresentations, falsifications 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 verified and that any material misrepresentation, falsification or omission may result in the denial or revocation of
my certificate(s), permit(s) or authorization(s).
ORIGINAL SIGNATURE OF APPLICANT:
DATE:
PAGE 1
Information on this application is subject to disclosure pursuant to the Freedom of Information Act.
Original Signatures Must Be On The Form Submitted
ED 170A
CONNECTICUT STATE DEPARTMENT OF EDUCATION
REV. 5/21
Bureau of Educator Standards and Certification
C.G.S. 10-145
P.O. Box 150471
C.G.S. 10-145d, P.A.
Hartford, CT 06115-0471
Regs. 10-145d-412
www.ct.gov/sde/cert
SHORT FORM APPLICATION FOR CONNECTICUT INITIAL EDUCATOR CERTIFICATE
Submit $200 (includes $50 nonrefundable application fee) money order, cashier’s
check or certified bank check payable to: “Treasurer, State of CT” (NO personal checks or cash accepted).
PART I: PERSONAL INFORMATION (Print all information in blue ink and in uppercase letters.)
LAST NAME
FIRST NAME
MI
GENDER
˗
˗
˗
˗
BIRTH DATE (Month-Day-Year) - Required
SOCIAL SECURITY NUMBER
ADDRESS (Street ONLY no P.O. Box)
Apt. #
(City)
(State)
˗
FORMER LAST NAME(S) Required
(Zip Code)
˗
˗
PHONE
(Home/Cell)
Race/Ethnicity
1.
Native American
˗
˗
2.
Asian/Pacific Islander
(Work)
3.
Black
(Optional)
4.
White
BACHELOR’S DEGREE
5.
Hispanic
STATE/COUNTRY
DEGREE AWARDED
Mo./Yr.
E-MAIL ADDRESS
1.
Have you ever been convicted of any crime, excluding minor traffic violations?
YES
NO
2.
Have you been dismissed for cause from any position?
YES
NO
3.
Have you ever surrendered a professional certificate, license, permit or other credential
YES
NO
(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?
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 official copies of court or administrative record(s), including disposition of each case.
Pursuant to Connecticut General Statutes Section 10-221d, the State Board of Education must submit, periodically, a database of applicants for an initial
issuance of a certificate, authorization or permit to the State Police Bureau of Investigation for a criminal history record check. Each applicant seeking an
initial issuance or renewal of a certificate, 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 criminal history records check the database of all persons who hold any certificate, authorization or permit.
APPLICANT ATTESTATION: I certify that the information provided by me on this application and any accompanying documents contains no material
misrepresentations, falsifications 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 verified and that any material misrepresentation, falsification or omission may result in the denial or revocation of
my certificate(s), permit(s) or authorization(s).
ORIGINAL SIGNATURE OF APPLICANT:
DATE:
PAGE 1
Information on this application is subject to disclosure pursuant to the Freedom of Information Act.
Original Signatures Must Be On The Form Submitted
ED 170A
SHORT FORM
STATEMENT OF PREPARING HIGHER EDUCATION INSTITUTION
This institutional recommendation must be signed by the administrative official authorized to make such recommendation (Dean of the
School of Education or Certification Officer) and MUST include the embossed or colored seal of the college or university.
Print all information in dark ink and in uppercase letters.
˗
˗
APPLICANT’S LAST NAME
FIRST NAME
MI
SOCIAL SECURITY NUMBER
NAME OF HIGHER EDUCATION INSTITUTION
CITY
STATE
ZIP CODE
1a. The applicant has successfully completed a planned program for certification in:
(endorsement codes)
1b.
Check box if the applicant completed a planned program for bilingual education in above discipline(s).
1c. Student teaching/practica/internship was completed at
(circle one)
(school/district)
in grade/subject
from
to
(grade/subject)
(date)
(date)
1d. Student teaching/practica/internship was completed at
(circle one)
(school/district)
in grade/subject
from
to
(grade/subject)
(date)
(date)
1e.
Check box if student teaching/practica/internship was waived on the basis of preapproved experience or if applicant taught under
a Durational Shortage Area Permit (DSAP). Please attach a written explanation and the Statement of Professional Experience
form.
1f.
Check box if candidate successfully completed edTPA Portfolio Tasks 1 & 3 during the 2020-21 SBE Portfolio Waiver Period.
2.
Subject area major
˗
˗
3.
Date applicant completed all planned program requirements
(month) (day) (year)
4. Check box if applicant is recommended for certification as a school psychologist with a deficiency for the internship.
5.
The applicant is unconditionally recommended for certification (has satisfactorily completed the
YES
NO
institution’s approved planned program, including the state’s testing requirements, has the qualities of
character and personal fitness for teaching, and is competent in the areas for which certification is sought).
TYPED OR PRINTED NAME OF RECOMMENDING OFFICIAL
TITLE
SIGNATURE OF RECOMMENDING OFFICIAL
DATE
TELEPHONE
FAX
E-MAIL
Check box if you are requesting additional endorsement(s) and
PLACE COLLEGE
submit official transcript(s).
OR UNIVERSITY
If eligible for the additional endorsement(s) requested, you will be
SEAL HERE
notified in writing and required to submit $100 for each
endorsement.
Additional endorsement(s) requested in:
(endorsement codes)
PAGE 2
ED 170A
CONNECTICUT STATE DEPARTMENT OF EDUCATION
REV. 5/21
Bureau of Educator Standards and Certification
C.G.S. 10-145
P.O. Box 150471
C.G.S. 10-145d, P.A.
Hartford, CT 06115-0471
Regs. 10-145d-412
www.ct.gov/sde/cert
SHORT FORM APPLICATION FOR CONNECTICUT INITIAL EDUCATOR CERTIFICATE
WHEN TO USE THIS FORM
This form is for individuals who completed an approved educator preparation program at a Connecticut
college or university after July 1, 1993. If you completed your program prior to July 1, 1993, or if you
completed your program outside of Connecticut, you must submit the general application form ED 170
and official transcripts.
Official transcripts must be submitted with this application.
If you have completed a planned program in an administrative endorsement area or remedial
reading and remedial language arts, you are required to provide verification of employment (Form
ED 126) upon review of your request.
You may use this application form to request the following:
An Initial Educator Certificate: Eligibility for this certificate is based upon the completion of an
approved preparation program at a Connecticut university or college and all required state assessments.
It is valid for three years.
Cross Endorsement(s): This application also may be used to request additional endorsements at the
time of application for an Initial Educator Certificate. Please check the box on the application and
indicate the additional endorsement(s) requested. Official transcripts must be submitted in order to verify
course work and must be sent to the bureau directly from the college/university. Subject-area
assessment scores (if applicable) must be reported to the Connecticut State Department of Education
directly from the testing service prior to the issuance of an endorsement. Upon review of official
transcripts and determination of your eligibility for cross endorsement, you will be notified in writing to
submit any additional fees required.
HOW TO COMPLETE THIS FORM
1. Complete ALL sections on front of application.
2. Ensure that the preparing institution completes the back of this application.
3. Attach official transcripts.
4. Attach the $200 fee in form of a money order, cashier’s check or certified bank check payable to the
“Treasurer, State of Connecticut”. Applicants who are eligible for more than one endorsement must
submit an additional $100 for each endorsement. Personal checks not accepted.
5. Mail completed form with fee to the address at the top of this page.
PLEASE NOTE: ALL TESTING RESULTS MUST BE REPORTED TO THE STATE DEPARTMENT
OF EDUCATION BY THE APPROPRIATE TESTING AGENCY PRIOR TO THE ISSUANCE OF A
CERTIFICATE.
ED 170A
CONNECTICUT STATE DEPARTMENT OF EDUCATION
REV. 5/21
Bureau of Educator Standards and Certification
C.G.S. 10-145
P.O. Box 150471
C.G.S. 10-145d, P.A.
Hartford, CT 06115-0471
Regs. 10-145d-412
www.ct.gov/sde/cert
INSTRUCTIONS FOR SHORT FORM APPLICATION FOR CONNECTICUT INITIAL EDUCATOR
CERTIFICATE
WHEN TO USE THIS FORM
This form is for individuals who completed an approved educator preparation program at a Connecticut college or university after
July 1, 1993. If you completed your program prior to July 1, 1993, or if you completed your program outside of Connecticut, you must
submit the general application form ED 170.
You may use this application form to request the following:
• An Initial Educator Certificate: Eligibility for this three year certificate is based upon the completion of an approved
Connecticut educator preparation program.
• Cross Endorsement(s): Please check the appropriate box on page two. Official transcripts must be submitted. We strongly
encourage electronic transcripts be sent directly by the college(s) or university to teacher.etranscript@ct.gov.
HOW TO COMPLETE THIS FORM
1.
Complete ALL sections on the front of the application.
2.
Ensure that the college/university completes page two of the application.
3.
Submit all electronic transcripts to teacher.etranscript@ct.gov.
4.
Submit your $200 fee in the form of a money order, cashier’s check or certified bank check payable to “Treasurer, State of
Connecticut.” Applicants who are eligible for more than one endorsement must submit an additional $100 for each
endorsement. Personal checks and cash are not accepted.
5.
Mail completed form with required fee to the address at the top of this page.
PLEASE NOTE:
In order to expedite processing time, please ensure your e-mail address is current and accurate.
CONNECTICUT ENDORSEMENT CODES
Teaching Endorsements
010
Business, 7–12
072
School Nurse-Teacher
015
English, 7–12
073
School Dental Hygienist-Teacher
018
French, 7–12
089
Marketing Education, 7–12
019
German, 7–12
101
World Language Instructor, Elementary
020
Italian, 7–12
102
Remedial Reading & Remedial Language Arts, 1–12
021
Latin, 7–12
104 Cooperative Work Education/Diversified Occupations
022
Russian, 7–12
110
Unique Subject-Area
023
Spanish, 7–12
111
Teaching English to Speakers of Other Languages (TESOL), PK–12
024
Other World Language, 7–12
112
Integrated Early Childhood/Special Ed., Birth–Kindergarten
026
History & Social Studies, 7–12
113
Integrated Early Childhood/Special Ed., Nursery -K–Elem. 1–3
029
Mathematics, 7–12
165
Comprehensive Special Education, K–12
030
Biology, 7–12
215
English, Middle School
031
Chemistry, 7–12
226
History & Social Studies, Middle School
032
Physics, 7–12
229
Mathematics, Middle School
033
Earth Science, 7–12
230
Biology, Middle School
034
General Science, 7–12
231
Chemistry, Middle School
035
Driver Education
232
Physics, Middle School
040
Agriculture, Pre-K–12
233
Earth Science, Middle School
041
Vocational Agriculture, 7–12
234
General Science, Middle School
042
Art, PK–12
235
Integrated Science, Middle School
043
Health, PK–12
305
Elementary, 1–6
044
Physical Education, PK–12
317
Portuguese, 7–12
045
Home Economics, PK–12
318
Mandarin Chinese, 7–12
047
Technology Education, PK–12
483
Dance, Pre-K–12
049
Music, PK–12
485
Theatre and Drama, Pre-K–12
055
Partially Sighted, PK–12
511
Montesori, Elementary, 1–6
057
Deaf and Hard of Hearing, PK–12
512
Montesori, Primary, Birth to Kindergarten
059
Blind, PK–12
826
Vocational Department Head: Trade Technology
062
School Library Media Specialist
Administrative Endorsements
Special Services Endorsements
085
School Business Administrator
061
Speech and Language Pathologist
092
Intermediate Administration or Supervision
068
School Counselor
093
Superintendent of Schools
070
School Psychologist
097
Reading and Language Arts Consultant
071
School Social Worker
105
Department Chairperson
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