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Free Connecticut Ed 170 PDF Template

The Connecticut Ed 170 form is a vital document for individuals seeking certification from the Connecticut State Department of Education. This application facilitates the process of obtaining an educator certificate, ensuring that all applicants meet the necessary standards and requirements. To begin your journey towards certification, please fill out the form by clicking the button below.

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The Connecticut Ed 170 form serves as a crucial document for individuals seeking certification as educators in the state. This application is managed by the Bureau of Educator Standards and Certification, which operates under the Connecticut State Department of Education. Applicants are required to submit a nonrefundable fee of $50, which must be paid via a money order, cashier’s check, or certified bank check made out to the Treasurer of the State of Connecticut. The form collects essential personal information, including the applicant's name, social security number, and contact details. It also poses several questions regarding any past criminal convictions or disciplinary actions related to professional credentials. Additionally, the Ed 170 requires applicants to disclose their educational history, including institutions attended and degrees earned, as well as their professional experience within the last decade. Furthermore, the form emphasizes the necessity of a criminal history record check and a review of the Department of Children and Families’ child abuse and neglect registry. If an applicant answers "yes" to any disqualifying questions, they must provide a signed statement of explanation and relevant documentation. Completing the Ed 170 accurately is essential, as any misrepresentation can lead to denial or revocation of certification. This form plays a significant role in ensuring that educators meet the standards set forth by the state, thereby contributing to the overall quality of education in Connecticut.

▼ Connecticut Ed 170 PDF Form

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File Information

Fact Name	Description
Purpose of ED 170	The ED 170 form is used for applying for a Connecticut educator certification.
Application Fee	A nonrefundable application fee of $50 is required, payable via money order, cashier’s check, or certified bank check.
Criminal History Check	Connecticut law mandates a criminal history record check for all applicants, as per C.G.S. 10-221d.
Child Abuse Registry Check	Applicants must also undergo a check with the Department of Children and Families’ child abuse and neglect registry, per C.G.S. 17a-101k.
Signature Requirement	Applicants must certify the accuracy of their information by signing the application, acknowledging potential verification of details.

Connecticut Ed 170 Sample

ED 170	CONNECTICUT STATE DEPARTMENT OF EDUCATION
	Bureau of Educator Standards and Certification

C.G.S. 10-145

C.G.S. 10-145d, P.A. 03-168

P.O. Box 150471

Hartford, CT 06115-0471

Enclose a NONREFUNDABLE application fee of $50 in the form of a money order,

cashier’s check or certified bank check payable to: “Treasurer, State of CT” (NO personal checks or cash accepted).

GENERALAPPLICATION FOR CERTIFICATE

LAST NAME
FIRST NAME				MI	GENDER
˗	˗	˗		˗
SOCIAL SECURITY NUMBER		BIRTH DATE (Month-Day-Year) - Required
ADDRESS (Street ONLY no P.O. Box)					Apt. #
(City)					(State)
	˗
(Zip Code)			FORMER LAST NAME(S) Required
PHONE	˗	˗
	˗	˗

(Home/Cell)

˗˗

(Work)

E-MAIL ADDRESS

1.Have you ever been convicted of any crime, excluding minor traffic violations?

2.Have you been dismissed for cause from any position?

3.Have you ever surrendered a professional certificate, license, permit or other credential (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?

Race/Ethnicity	1.	Native American
	2.	Asian/Pacific Islander
(Optional)	3.	Black
(Optional)	4.	White
	5.	Hispanic

YES NO

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.

ED 170

(See enclosed code list.)

ENDORSEMENT #1 ENDORSEMENT #2 ENDORSEMENT #3 ENDORSEMENT #4

Check box if bilingual endorsement is sought for above discipline(s).

If requesting endorsement 090, 098, please indicate the specific occupational/vocational area (e.g., carpentry)

LIST THE NAMES OF COLLEGES OR UNIVERSITIES ATTENDED
Name of Institution	State	Major Field	Year of	College Credit or
		of Study	Graduation	Degree Awarded

Please provide your education and work (within the last ten years) history, starting with your most recent position. Do not include student teaching, substitute or paraprofessional experience. Attach an additional sheet of paper, if needed.

NAME OF SCHOOL

LOCATION (City, State)

JOB TITLE

SUBJECT/FIELD

GRADE(S)

DATES EMPLOYED

FROM (M/Y) TO (M/Y)

(specify state and type of certificate)

(Attach a copy of both sides of out-of-state certificates, covering any of the experiences listed above that are within the last 10 years.)

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:

Information on this application is subject to disclosure pursuant to the Freedom of Information Act.

ED 170

010Business, 7–12

015English, 7–12

018French, 7–12

019German, 7–12

020Italian, 7–12

021Latin, 7–12

022Russian, 7–12

023Spanish, 7–12

024Other World Language, 7–12

026History & Social Studies, 7–12

029Mathematics, 7–12

030Biology, 7–12

031Chemistry, 7–12

032Physics, 7–12

033Earth Science, 7–12

034General Science, 7–12

035 Driver Education

040 Agriculture, Pre-K–12

041Vocational Agriculture, 7–12

042Art, PK–12

043Health, PK–12

044Physical Education, PK–12

045Home Economics, PK–12

047Technology Education, PK–12

049Music, PK–12

055Partially Sighted, PK–12

057Deaf and Hard of Hearing, PK–12

059Blind, PK–12

062School Library Media Specialist

072 School Nurse-Teacher

073School Dental Hygienist-Teacher

089Marketing Education, 7–12

101World Language Instructor, Elementary

102Remedial Reading & Remedial Language Arts, 1–12

104Cooperative Work Education/Diversified Occupations

110Unique Subject-Area

111Teaching English to Speakers of Other Languages (TESOL), PK–12

112Integrated Early Childhood/Special Ed., Birth – Kindergarten

113Integrated Early Childhood/Special Ed., Nursery -K–Elem. 1–3

165Comprehensive Special Education, K–12

215English, Middle School

226History & Social Studies, Middle School

229Mathematics, Middle School

230Biology, Middle School

231Chemistry, Middle School

232Physics, Middle School

233Earth Science, Middle School

234General Science, Middle School

235Integrated Science, Middle School

305Elementary, 1–6

317Portuguese, 7–12

318Mandarin Chinese, 7–12

483Dance, Pre-K–12

485Theatre and Drama, Pre-K–12

511Montesori, Elementary, 1–6

512Montesori, Primary, Birth to Kindergarten

826Vocational Department Head: Trade Technology

085	School Business Administrator	088	Non-English Speaking Adults
092	Intermediate Administration or Supervision	106	High School Credit Diploma Program
093	Superintendent of Schools	107	External Diploma Program/Noncredit Mandated Programs

097Reading and Language Arts Consultant

105Department Chairperson

061	Speech and Language Pathologist	082	Vocational Technical Administrator
068	School Counselor	090	Occupational Subject, Vocational Technical Schools
070	School Psychologist	091	Trade-Related Subjects, Vocational Technical Schools
071	School Social Worker	098	Trade & Industrial Occupations – Comprehensive High School
268	School Marriage & Family Therapist	103	Health Occupations – Comprehensive High School
		108	Practical Nurse Education Instruction
		109	Health Occupations – Vocational Technical Schools

001	Pre-K–Grade 8	053	Physically Handicapped, 1–12
002	Pre-K–Grade 6	054	Physically Handicapped, 7–12
003	Pre-K–Grade 3	056	Partially Sighted, 7–12
004	Grades 1–8	058	Deaf, 7–12
005	Elementary Education, 1–6	060	Blind, 7–12
006	Middle Grades, 4–8	063	Special Teacher of Reading, 1–8
007	Academic Subjects	064	Special Teacher of Reading, 7–12
008	Pre-K and Kindergarten	065	Comprehensive Special Education, PK–12
009	Bilingual, PK–12	066	Guidance Counselor – Elementary
011	Licensed Practical Nurse	067	Guidance Counselor – Secondary
013	Elementary, K–6	069	Psychological Examiner
016	English, 7–9	074	Elementary Principal
017	Speech, 7–12	075	General Supervisor – Elementary
025	History, 7–12	076	Secondary Principal
027	Social Studies, 7–12	077	General Supervisor – Secondary
028	History & Social Studies, 7–9	078	Principal – Combined School
036	Core Curriculum	079	Special Supervisor
037	Psychology, 7–12	080	Administrative Assistant
038	Sociology, 7–12	081	Superintendent of Schools
039	Secondary Subject	083	Special Administrative
046	Vocational Home Economics, PK–12	086	Director of Adult Education (Full Time)
048	Librarian, 7–12	087	Director of Adult Education (Part Time)
050	Special Subject	094	Adult Education
051	Mentally Handicapped 1–12	095	Education Supervisor (State Department) 096
052	Mentally Handicapped 7–12	265	Comprehensive Special Education, 1–12

ED 170	CONNECTICUT STATE DEPARTMENT OF EDUCATION
	Bureau of Educator Standards and Certification

C.G.S. 10-145

C.G.S. 10-145d, P.A. 03-168

P.O. Box 150471

Hartford, CT 06115-0471

INSTRUCTIONS FOR GENERALAPPLICATION FOR CERTIFICATION

•continuation of a Connecticut Professional Educator Certificate (please use Form ED 179); or

•renewal of an Initial Educator Certificate (please use Form ED 183).