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Official Connecticut Ed 174 Template in PDF

The Connecticut Ed 174 form is an application used to obtain a Substitute Teacher Authorization for individuals who have not completed a bachelor’s degree. This form collects personal information, educational background, and attestation from the applicant. It is essential for candidates seeking to work as substitute teachers in Connecticut schools.

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Official Connecticut Ed 174 Template in PDF

Structure

The Connecticut Ed 174 form is a critical document for individuals seeking authorization to serve as substitute teachers without having completed a bachelor's degree. This application, administered by the Connecticut State Department of Education, requires candidates to provide personal information, including their name, contact details, and social security number. Additionally, applicants must disclose any past criminal convictions or disciplinary actions related to their professional credentials. This transparency is essential, as the State Board of Education conducts thorough background checks, including a review of criminal history and child abuse registries, to ensure the safety of students. The form also includes sections for educational background and relevant experience working with children, allowing candidates to showcase their qualifications. Furthermore, the application mandates an attestation from the applicant, affirming the truthfulness of the provided information, and requires a signature from a school district official, confirming the applicant's eligibility for employment. As the authorization is temporary, expiring on June 30 of the school year it was approved, timely submission of the completed form and supporting documents is crucial for prospective substitute teachers.

Connecticut Ed 174 Example

	ED 174	CONNECTICUT STATE DEPARTMENT OF EDUCATION
	REV. 1/12	Bureau of Educator Standards and Certiication
	C.G.S. 10-145, P.A. 11-27	P.O. Box 150471 – Room 243
	C.G.S. 10-145d	P.O. Box 150471 – Room 243
	C.G.S. 10-145d	Hartford, CT 06115-0471
	Regs. 10-145d-420	Hartford, CT 06115-0471
		www.ct.gov/sde

APPLICATION FOR SUBSTITUTE TEACHER AUTHORIZATION

FOR CANDIDATES WHO HAVE NOT COMPLETED A BACHELOR’S DEGREE

PART I: PERSONAL INFORMATION (Print all information in dark ink and in uppercase letters.)

LAST NAME

FIRST NAME

GENDER (M/F)

–

SOCIAL SECURITY NUMBER

BIRTH DATE (Month-Day-Year) – Required

ADDRESS (Street)

(Apt #)

(City)

–

FORMER LAST NAME(S)

(State)

(Zip Code)

PHONE

–

Race/Ethnicity

Native American

(Home/Cell)

Asian/Paciic Islander

E-MAIL ADDRESS

Black

(Optional)

White

Hispanic

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

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?

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 174

PART II: EDUCATIONAL BACKGROUND

List all education you have completed, including high school, trade-related vocational school and/or other postsecondary schooling.

NAME OF SCHOOL

STATE DATES ATTENDED

From (M/Y) To (M/Y)

EDUCATION LEVEL COMPLETED

(H.S. Diploma, GED, Assoc. Degree)

List ALL substitute teaching experience or any other experiences you have had working with school-age children, along with any unique qualiications for the substitute position. (Please attach your resume, or a separate sheet, if necessary.)

PART III: 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:

PART IV: EMPLOYING AGENT INFORMATION AND ATTESTATION

The applicant will serve only as a substitute teacher in random assignments and only up to 40 days in one assignment.

Signature of Superintendent, Executive Director or designee attesting to the accuracy of information

(Original Signature: No Signature Stamps Accepted)

Typed or Printed Name of Person Signing Above

District

Street

City,

State, Zip Code

FOR OFFICE USE ONLY

The person named on this application is authorized of education listed above.

Authorized Signature:

Date

Title

Telephone

FAX Number

E-mail Address

is NOT authorized to serve as a substitute teacher for the board

Date:

Original Signatures Must Be On Form Submitted

PAGE 2

ED 174	CONNECTICUT STATE DEPARTMENT OF EDUCATION
REV. 1/12	Bureau of Educator Standards and Certiication
REV. 1/12
C.G.S. 10-145, P.A. 11-27	P.O. Box 150471 – Room 243
C.G.S. 10-145d	P.O. Box 150471 – Room 243
Regs. 10-145d-420	Hartford, CT 06115-0471
	Hartford, CT 06115-0471
	www.ct.gov/sde

INSTRUCTIONS TO APPLICATION FOR SUBSTITUTE TEACHER AUTHORIZATION

FOR CANDIDATES WHO HAVE NOT COMPLETED A BACHELOR’S DEGREE

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 Certi- ication to process your request for a Substitute Teacher Authorization for candidates who have NOT completed a bachelor’s degree. This authorization will expire on June 30 of the school year during which it was approved.

Applicant:

a. Complete Parts I, II and III.

b. Return completed application to the superintendent of schools, executive director or designee.

Employing Agent:

a. Complete Part IV and mail application and supporting documentation to the Bureau of Educator Standards and Certiication at the above address.

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

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Document Specifications

Fact Name	Fact Description
Form Purpose	The ED 174 form is used to apply for a Substitute Teacher Authorization for candidates who have not completed a bachelor's degree.
Governing Laws	The form is governed by Connecticut General Statutes (C.G.S.) 10-145 and Public Act (P.A.) 11-27.
Submission Address	Applications must be sent to the Bureau of Educator Standards and Certification, P.O. Box 150471, Room 243, Hartford, CT 06115-0471.
Application Validity	The Substitute Teacher Authorization expires on June 30 of the school year in which it was approved.
Criminal Background Check	Applicants must undergo a criminal history records check as mandated by C.G.S. Section 10-221d.
Child Abuse Registry Check	A check of the Department of Children and Families’ child abuse and neglect registry is required for applicants.
Personal Information Required	Applicants must provide personal information, including name, social security number, and contact details.
Educational Background	Applicants must list all completed education, including high school and any postsecondary schooling.
Experience Documentation	Applicants should detail any substitute teaching experience or work with school-age children, attaching a resume if necessary.
Signature Requirement	Original signatures are required from both the applicant and the employing agent; no signature stamps are accepted.

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