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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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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

REV. 7/19

C.G.S. 10-145, P.A. 11-27

C.G.S. 10-145d

Regs. 10-145d-420

CONNECTICUT STATE DEPARTMENT OF EDUCATION

Bureau of Educator Standards and Certication

P.O. Box 150471

Hartford, CT 06115-0471

www.ct.gov/sde/cert

APPLICATION FOR SUBSTITUTE TEACHER AUTHORIZATION

FOR CANDIDATES WHO HAVE NOT COMPLETED A BACHELOR’S DEGREE

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)

(Work)

E-MAIL ADDRESS

1. Haveyoueverbeenconvictedofanycrime,excludingminortracviolations? YES NO

2. Haveyoubeendismissedforcausefromanyposition? YES NO

3. Haveyoueversurrenderedaprofessionalcerticate,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certicate,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certicate,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certicate,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ocial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

Race/Ethnicity

(Optional)

1. Native American

2. Asian/PacicIslander

3. Black

4. White

5. Hispanic

˗ ˗

PAGE 2

Original Signatures Must Be On Form Submitted

ED 174

PART II: EDUCATIONAL BACKGROUND

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

ListALLsubstituteteachingexperienceoranyotherexperiencesyouhavehadworkingwithschool-agechildren,alongwithanyunique

qualications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,

falsications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).

By checking the "I Agree" box, you agree your typed signature is the legal equivalent of your manual signature on this Application.

I Agree.

DATE:

PART IV: EMPLOYING AGENT INFORMATION AND ATTESTATION

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:

SignatureofSuperintendent,ExececutiveDirectorordesignee

attestingtotheaccuracyofinformation

(Original signature, no stamps accepted)

TypedorPrintedNameofPersonSigningAbove

District

Street

City, State, Zip Code

Date

Title

Telephone

FAX Number

E-mailAddress

NAME OF SCHOOL STATE DATES ATTENDED

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

EDUCATION LEVEL COMPLETED

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

ORIGINAL SIGNA TURE OF APPLICANT:

ED 174

REV. 7/19

C.G.S. 10-145, P.A. 11-27

C.G.S. 10-145d

Regs. 10-145d-420

CONNECTICUT STATE DEPARTMENT OF EDUCATION

Bureau of Educator Standards and Certication

P.O. Box 150471

Hartford, CT 06115-0471

www.ct.gov/sde/cert

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

ListbelowaretherequireddocumentswhichmustbesubmittedtotheBureauofEducatorStandardsandCertication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andII.

 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 

  Certication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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