
LAST NAME
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.)
FIRST NAME MI
SOCIAL SECURITY NUMBER BIRTH DATE (Month-Day-Year) – Required
ADDRESS (Street) (Apt #)
(City)
(State) (Zip Code)
FORMER LAST NAME(S)
PHONE
(Home/Cell)
1. Have you ever been convicted of any
NOTE:
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Race/Ethnicity 1. Native American
3. Black
(Optional) 4. White
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E-MAIL ADDRESS
Information on this application is subject to disclosure pursuant to the Freedom of Information Act.
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ED 174
REV. 1/12
C.G.S. 10-145, P.A. 11-27
C.G.S. 10-145d
Regs. 10-145d-420
CONNECTICUT STATE DEPARTMENT OF EDUCATION
P.O. Box 150471 – Room 243
Hartford, CT 06115-0471
www.ct.gov/sde
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