Application For Temporary Emergency Coaching Permit printable pdf download

ED 186

CONNECTICUT STATE DEPARTMENT OF EDUCATION

REV. 3/12

Bureau of Educator Standards and Certification

C.G.S. 10-145

P.O. Box 150471 – Room 243

C.G.S. 10-145d

Hartford, CT 06115-0471

C.G.S. 10-149

C.G.S. 10-149b

Regs. 10-145d-424

APPLICATION FOR TEMPORARY EMERGENCY COACHING PERMIT

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

1. Native American

(Home/Cell)

2. Asian/Pacific Islander

3. Black

(Optional)

4. White

E-MAIL ADDRESS

5. Hispanic

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

YES NO

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

YES NO

3. Have you ever surrendered a professional certificate, 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 certificate, authorization or permit. 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 a 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 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

Application For Temporary Emergency Coaching Permit

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