Form ED175 "Application for Extension of Substitute Teacher Authorization Beyond the 40-day Limit" - Connecticut

What Is Form ED175?

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 July 1, 2019;
  • 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 fillable version of Form ED175 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 ED175 "Application for Extension of Substitute Teacher Authorization Beyond the 40-day Limit" - Connecticut

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ED 175
CONNECTICUT STATE DEPARTMENT OF EDUCATION
REV. 7/19
Bureau of Educator Standards and Certification
C.G.S. 10-145
P.O. Box 150471
C.G.S. 10-145d, P.A. 03-168
Hartford, CT 06115-0471
Regs. 10-145d-420
www.ct.gov/sde/cert
APPLICATION FOR EXTENSION OF SUBSTITUTE TEACHER
AUTHORIZATION BEYOND THE 40-DAY LIMIT
PART I: PERSONAL INFORMATION (Print all information in blue ink and in uppercase letters.)
LAST NAME
FIRST NAME
MI
GENDER
˗
˗
˗
˗
SOCIAL SECURITY NUMBER
BIRTH DATE (Month-Day-Year) - Required
ADDRESS (Street)
Apt. #
(City)
(State)
˗
FORMER LAST NAME(S)
(Zip Code)
˗
˗
PHONE
(Home)
1.
Native American
Race/Ethnicity
˗
˗
2. Asian/Pacific Islander
3.
Black
(Work)
4.
White
(Optional)
5. Hispanic
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?
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.
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 use.
Information on this application is subject to disclosure pursuant to the Freedom of Information Act.
PAGE 1
ED 175
CONNECTICUT STATE DEPARTMENT OF EDUCATION
REV. 7/19
Bureau of Educator Standards and Certification
C.G.S. 10-145
P.O. Box 150471
C.G.S. 10-145d, P.A. 03-168
Hartford, CT 06115-0471
Regs. 10-145d-420
www.ct.gov/sde/cert
APPLICATION FOR EXTENSION OF SUBSTITUTE TEACHER
AUTHORIZATION BEYOND THE 40-DAY LIMIT
PART I: PERSONAL INFORMATION (Print all information in blue ink and in uppercase letters.)
LAST NAME
FIRST NAME
MI
GENDER
˗
˗
˗
˗
SOCIAL SECURITY NUMBER
BIRTH DATE (Month-Day-Year) - Required
ADDRESS (Street)
Apt. #
(City)
(State)
˗
FORMER LAST NAME(S)
(Zip Code)
˗
˗
PHONE
(Home)
1.
Native American
Race/Ethnicity
˗
˗
2. Asian/Pacific Islander
3.
Black
(Work)
4.
White
(Optional)
5. Hispanic
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?
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.
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 use.
Information on this application is subject to disclosure pursuant to the Freedom of Information Act.
PAGE 1
ED 175
PART II: EDUCATIONAL BACKGROUND
1.
List all education you have completed, including high school, trade-related vocational school and/or other postsecondary schooling.
NAME OF INSTITUTION
MAJOR FIELD
DEGREE
STATE
DATES ATTENDED
OF STUDY
AWARDED
From (M/Y) To (M/Y)
2.
If a bachelor’s degree is required for the subject(s) and grade level(s) of the substitute teaching assignment(s), official transcripts are
attached verifying the completion of the required bachelor’s degree and 12 semester hours of credit in the area(s) requested.
3.
If this request is for an occupational or trade-related subject for which a bachelor’s degree is not required, you must attach verification
of eight years of appropriate occupational experience. Verification of experience must be submitted on company letterhead. If you are
self-employed, we will accept a notarized statement and photocopies of tax records.
PART III: APPLICANT ATTESTATION
I have reviewed this application and affirm that the information provided by me on this application and any accompanying documents
contains no material misrepresentations, falsifications or omissions and that all 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).
By checking the "I Agree" box, you agree your typed signature is the legal equivalent of your manual signature on this Application.
I Agree.
ORIGINAL SIGNA TURE OF APPLICANT:
DATE:
PART IV: EMPLOYING AGENT INFORMATION
1.
Indicate the subject(s) and grade level(s) of the substitute teaching assignment(s), including occupational or trade-related subjects for
which a bachelor’s degree is not required.
Subject
Grade Level
Subject
Grade Level
2.
Attach a letter documenting steps taken by the board of education to secure a certified candidate suitable for this position. Please
indicate the number of certified applicants who applied for this position and identify the reasons why a certified candidate was not
hired. Additionally, indicate any circumstances and conditions which make this position particularly difficult to staff.
3.
List and attach a copy of the specific location and dates of newspaper advertisements, vacancy notices, university postings, teacher
agency contacts, Internet job postings, etc.
PART V: EMPLOYING AGENT ATTESTATION
I am requesting an extension of substitute teacher authorization beyond the 40-day limit for the candidate listed on this application. I
understand that, if approved, this candidate may serve in this position until June 30 of the current school year.
Signature of Superintendent, Executive Director or designee attesting to
Date
the accuracy of information
(Original signature, no stamps accepted)
Typed or Printed Name of Person Signing Above
Title
District
Telephone Number
Street
FAX Number
City,
State,
Zip Code
E-Mail Address
Original Signatures Must Be On Form Submitted
PAGE 2
ED 175
CONNECTICUT STATE DEPARTMENT OF EDUCATION
REV. 7/17
Bureau of Educator Standards and Certification
C.G.S. 10-145
P.O. Box 150471
C.G.S. 10-145d, P.A. 03-168
Hartford, CT 06115-0471
Regs. 10-145d-420
www.ct.gov/sde/cert
INSTRUCTIONS TO APPLICATION FOR EXTENSION OF SUBSTITUTE TEACHER
AUTHORIZATION BEYOND THE 40-DAY LIMIT
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 Certification to
process your request for a Substitute Teacher Authorization Beyond the 40-Day Limit. This authorization will expire on
June 30 of the school year during which it was approved.
Applicant:
a. Complete Parts I and II.
b. Attach official transcript(s), signed and sealed by the registrar(s), indicating the completion of a bachelor’s degree and a
minimum of 12 semester hours of credit in the area(s) requested. Official transcripts must include the embossed or colored
seal of the college or university.
c. Return completed application to the superintendent of schools, executive director or designee.
Employing Agent:
a. Complete Parts IV and V and mail application and supporting documentation to the Bureau of Educator Standards and
Certification at the above address.
FOR OFFICE USE ONLY
The person named on this application
is authorized
is NOT authorized to serve as a substitute teacher for the board of
education listed on page 2.
Authorized Signature:
Date:
Page of 3