Fillable APPLICATION FOR CREDENTIAL AUTHORIZING PUBLIC SCHOOL SERVICE (Form (California)

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APPLICATION FOR CREDENTIAL AUTHORIZING PUBLIC SCHOOL SERVICE (Form (California)

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__________________________________________________________________________________________
APPLICATION FOR CREDENTIAL AUTHORIZING
PUBLIC SCHOOL SERVICE (Form 41-4)
Instruction and Information Sheet
COMPLETING YOUR APPLICATION
This application form may be used to apply for or renew any credential, certificate, or permit type with
the exception of variable term waivers. A separate application form and fee is required for each
credential for which you apply. You must use the current version of application Form 41-4,
which is available for download from the Commission’s website.
Type or print all information requested on the application form. Applications not completely and
accurately filled in and accompanied by all required supporting materials will be returned to
the applicant. It is best to fill out the application form online and print it rather than fill it out by
hand to assure it is fully legible. It is advisable to print an extra copy to keep with your records until
your credential is issued.
You must not submit an application to the Commission with handwritten changes to any
information required to process your application. Applications with blotted out, crossed out,
or whited out changes will be returned and a new Form 41-4 complete and free from errors will
be required.
1. PERSONAL INFORMATION
You must complete all the required fields (*) in the Personal Information section, including your full
legal name and list all former names, including your maiden name, if applicable. Additionally, you are
required to provide your full Social Security Number (SSN) or Individual Tax Identification Number
(ITIN) on your application pursuant to 42 USC §666 and California Family Code §17520. If this
information is not furnished, your application will be returned to you for completion. For more
information, see Coded Correspondence 13-14 on the Commission’s website.
You must provide the Commission with a valid email address on your application form to
receive automated notifications regarding your application and credential status.
Current document holders note: If you have legally changed your name, you must submit by postal
mail a completed Form 41-NC to the Commission along with any required documentation as indicated
on the form.
You are required to notify the Commission of any address change pursuant to 5 CCR §80412. A
change of mailing or email address may be completed online by using this link for the Educator Login
button on the Commission’s website.
2. APPLICATION TYPE
Select the one category most appropriate to the purpose of the application. Make only one choice in
this section.
41-4 INSTRUCTIONS 6/2019 PAGE 1 of 5
3. CHOOSE DOCUMENT TYPE
Pick the document type you wish to apply for from this section. If the document type you are seeking is
not listed here, you can use one of the “Other” boxes in this section to indicate the type of document
sought with this application. A separate application form and fee is required if you wish to apply
for more than one credential type.
4. SELECT AUTHORIZATION/SUBJECT AREA(S)
Use the spaces shown, whether an open space or drop down box, to select the subject area or type of
authorization to list on the credential or permit sought. If seeking more than one subject area on a
Single Subject Credential, you may indicate additional subject areas in the Comments section on page
5 of the application form. The Commission has the authority to determine the term of any credential
issued.
5. CHILD DEVELOPMENT PERMIT RENEWAL: SELF-VERIFICATION
This section should be completed only by applicants who hold a Child Development Permit
(other than the Associate Teacher Permit) and seek to renew the permit. You may either complete
the self-verification in Section 5 on Form 41-4 or submit Form CL-826, the Professional Growth Plan
and Record along with your application. If you choose to self-verify completion of your professional
growth activities, you may be subject to an audit. If the audit determines that you did not complete the
professional growth requirements, your credential will not be renewed and you may be subject to
adverse action on other credentials you currently hold. You must retain your Professional Growth Plan
and Record Form for one year following the submission of your application.
6. PROFESSIONAL FITNESS QUESTIONS
You are required to answer all Professional Fitness Questions. Before granting your application, the
Commission will review your criminal history, if any, from the Federal Bureau of Investigation and
California Department of Justice, a national database of teacher misconduct, previous reviews by the
Commission, complaints from those with first-hand knowledge of misconduct, notifications from school
districts, and teacher preparation test score violations.
You must disclose misconduct, even if:
• It happened a long time ago
• It happened in another state, federal court, military or jurisdiction outside the United States
• You did not go to court and your attorney went for you
• You did not go to jail or the sentence was only a fine or probation
• You received a certificate of rehabilitation
• Your conviction was later dismissed (even if under Penal Code section 1203.4), expunged, set
aside or the sentence was suspended
In accordance with Health & Safety Code sections 11361.5 and 11361.7, you may omit misdemeanor
marijuana-related convictions that occurred more than two years prior to this application, except
convictions involving concentrated cannabis, which must be disclosed regardless of the date of such
a conviction.
41-4 INSTRUCTIONS 6/2019 PAGE 2 of 5
7. CHILD ABUSE AND NEGLECT MANDATED REPORTING
8. EMPLOYING AGENCY INFORMATION
9. OATH AND AFFIDAVIT
Warning: Failure to disclose any information requested is falsification of your application and
the Commission may reject or deny your application or take disciplinary action against your
credential. If you answer “yes” to a question, you must complete a Professional Fitness Explanation
Form and provide all requested documentation. If any of the records have been purged or are
otherwise not available, provide an original statement from the agency on its official letterhead
verifying that fact.
Pursuant to Education Code section 44252, you must read this section and mark the box “I agree,”
verifying that you understand your duties under the Child Neglect and Abuse Reporting Act (Penal
Code §11164). Applications received by the Commission after January 1, 2015 must include the
mandatory reporter acknowledgement or they will be returned to the sender. Please use the most
current version of Form 41-4 available on the website.
If you are seeking employment based on an emergency or teaching permit (other than a 30-Day or
Prospective Substitute Permit), a one-year nonrenewable credential, or intern credential, this section
must be completed by the employing school agency and submitted to the Commission by that
agency. Individuals applying directly to the Commission for other types of documents should
not to complete this section.
You must complete all portions of this section and certify (or declare) under penalty of perjury under
the laws of California that all the foregoing statements in this application are true and correct by
signing the oath.
ADDITIONAL INFORMATION ON APPLICATION SUBMISSION
Supporting Documentation
You are responsible for providing the appropriate official transcripts, letters verifying experience,
exam score reports, and any other information needed to determine your eligibility for the credential
sought with each application you submit. Transcripts or other supporting materials sent
separately from the submission of an application and payment or from a Commission letter
requesting the documentation are destroyed without being reviewed. The Commission cannot
match pieces of an application that arrive separately.
“Official transcripts” refers to the original college issued documents, not photocopies. Internet PDF
printouts and student grade reports are not acceptable. Official transcripts submitted with an
application need not remain sealed in the original envelope so an educator can verify these for
accuracy. Employing agencies and program sponsors submitting paper applications on behalf of
applicants may submit verified true copies of official transcripts.
The Commission will accept electronic versions of official transcripts (e-transcripts) when verification
is provided that the transcripts were submitted directly from the college or university to a school
district, county office, or credential program sponsor. Such verification is usually provided on the e-
transcript coversheet or each page of the transcript. The Commission will not accept e-transcripts
that were sent directly to an individual educator.
41-4 INSTRUCTIONS 6/2019 PAGE 3 of 5
All supporting documentation, including transcripts, becomes the property of the Commission when
submitted and will not be returned. The Commission does not maintain a file of all supporting
materials sent with every application. Educators should retain a copy of each application and the
related supporting materials submitted to the Commission for reference.
Fees
Please refer to the Commission’s fee schedule (Credential Leaflet CL-659) to determine the amount
due. Application fees may be paid by check or money order, made payable to the Commission on
Teacher Credentialing or CTC. Do not send cash. A service charge of $20 will be assessed for a
check that does not clear the bank and your credential may be voided until all fees due are
paid in full. If you are applying through a county office of education or school district office, you may
be asked to make the check payable to that agency so that they can submit a single check to the
Commission for all of their applicants. Applications submitted without the appropriate payment
will not be processed and will be returned.
Your application and fee remain valid for sixty (60) days (Reference: Title 5, California Code of
Regulations, section 80487). Application fees are earned upon receipt and are not refundable. If
you do not qualify for the credential type originally applied for, the fee cannot be used to apply for
another credential type. If requirements for a document are met after the initial submission of an
application, a new application and fee will be required.
Fingerprint Information
If this is your first application for a credential, certificate, or permit, you must provide verification that
you have completed fingerprint processing. California residents must complete the electronic
Live Scan process and do not have the option of submitting fingerprint cards. Individuals
applying for their first credential who reside outside California must submit with their application
packet two fingerprint cards (FD-258) and the additional fingerprint processing fees. A copy of the
Live Scan form (Form 41-LS) may be downloaded from the Commission’s website. Please see
Credential Leaflet CL-271 for more information on fingerprint processing.
Application Processing
Applications are processed in the date order in which they are received. Commission staff cannot
search for pending applications or process applications out of order. You may check your application
status online using the Educator Login to find the date it was received by the Commission. Click here
for the current processing date.
Current law sets a maximum processing time for the evaluation of applications of 50 business days
after the Commission receives a completed application. Applications delayed for completion of a
fitness review or fingerprint processing are not subject to the 50-day restriction. Please wait until the
maximum processing time has passed before contacting the Commission regarding your
application status.
Following the submission of the application, fee, and supporting materials, the application will be
evaluated to verify eligibility for the document requested. If you receive a letter requesting additional
information to complete your application (it may or may not be accompanied by your original
application), you must attach the requested documentation to the Commission’s letter and resubmit
all items by postal mail within 60 days of the date on the Commission’s letter or a new application and
fee will be required. If your application was also returned for correction, you must return the original
application along with any corrections submitted.
41-4 INSTRUCTIONS 6/2019 PAGE 4 of 5
Privacy
The California Information Practices Act and the Federal Privacy Act provide that agencies requesting
information indicate the principal purposes for which that information is used. Your name, former
names, SSN, date of birth, address, email address, and telephone numbers are used to provide
proper identification of your file and, if necessary, to contact you. Other information is used to
determine your eligibility.
Information displayed online regarding the documents you hold or have held is public information and
may be disclosed. In addition, pursuant to Education Code section 44230 the Commission may
disclose to the agency that submitted the application all information provided with applications
submitted by you through that agency. Information may also be disclosed to other State or Federal
agencies as authorized by law. Personal information may be disclosed to the public only with your
permission or in accordance with the law. The information is necessary for the Commission to
perform its duty under Education Code sections 44200-44439.
You have a right to review personal information maintained on you by the Commission unless access
is exempted by law. The Director of the Certification Division, 1900 Capitol Avenue, Sacramento,
California 95811-4213, is responsible for the maintenance of this information.
Online Credential View and Print Process
The Commission does not print or mail documents. The official record of credentials, certificates, and
permits is available through an online view to colleges, universities, and employers through the
Search for an Educator option on the Commission’s Home page (see the drop down under the
Employers link). Document holders may access their file using the Educator Login button on the
Commission’s Home page. Documents are available for view within 3-5 business days of issuance.
For directions on obtaining an unofficial copy of your document, see the instructions under the drop
down link Print a Document’s Detail for assistance.
Before you seal the envelope:
Be sure you have included the items listed below, all professional fitness questions are answered and
that the oath and affidavit has been signed and dated. Incomplete applications will be returned to
the applicant.
□ Completed application you must use the current version of Form 41-4
□ Exam score reports, when applicable
□ Official transcripts and other supporting materials, including Professional Fitness
Explanation Form, as applicable
□ Full payment (see Fee Information leaflet CL-659)
First-time California credential applicants must also include:
□ Live Scan receipt (form 41-LS) or for out-of-state/country residents only, two completed
fingerprint cards (FD-258)
Mail the completed application and payment to:
Commission on Teacher Credentialing
Certification Division
1900 Capitol Avenue
Sacramento, CA 95811-4213
41-4 INSTRUCTIONS 6/2019 PAGE 5 of 5
APPLICATION FOR CREDENTIAL AUTHORIZING PUBLIC SCHOOL SERVICE
(For Privacy Act Notification see Application Instructions)
Mail application and payment
(check or money order) to:
Commission on Teacher Credentialing
Certification Division
1900 Capitol Avenue
Sacramento, California 95811-4213
Appeal:
Route to:
Commission Use Only: Fee Information
APP
FP
Other
CTC Use Only
IHE/County/District Use Only
Issuance
Date:_
Email:
1. PERSONAL INFORMATION (type or print)
*
Social Security or Individual Tax Identification Number: *Date of Birth: (mm/dd/yyyy)
*My Full Legal Name:
First
\
Middle
\
Last
All Former/Maiden Name(s): County/District of Employment (CA only):
*Address:
*City:
*State:
*Zip:
Home Phone:
Work Phone:
Mobile Phone:
*Email Address:
* = Required Information
2. APPLICATION TYPE REQUESTED: (select only one option)
New Credential/Permit
Extension by Appeal Upgrade (Clear Credential or Child Development Permit)
Renewal
Add Subject/Authorization to Existing Document
Change of Restriction
Other:
3. CHOOSE DOCUMENT TYPE: (make only one selection in this section)
* = Available at the request of a California Local Education Agency (LEA) only. Documents in bold font require you
to select from Section 4 below a Subject or Authorized Area of Service to be listed on the document.
TEACHING CREDENTIALS:
SERVICES CREDENTIALS:
EMERGENCY PERMITS*:
Limited Assignment*
Short-Term Staff*
Provisional Internship*
EM CLAD*
EM Bilingual*
EM Teacher Librarian*
EM Resource Specialist*
SUBSTITUTE PERMITS:
30-Day Substitute
Career Substitute*
Prospective Substitute
Teaching Permit for
Statutory Leave*
30-Day CTE Substitute
CHILD DEVELOPMENT
PERMITS:
Assistant
Associate Teacher
Teacher
Master Teacher
Site Supervisor
Program Director
Children's Center
Permit
School-Age
Emphasis
4. SELECT AUTHORIZATION/SUBJECT AREA(S): (to choose additional subject areas, see page 5 “Comments” box)
Multiple Subject (Elementary Teaching)
Single Subject (Secondary Teaching):
(Specify World Language-if applicable)
Special Education Specialty Areas:
CTE Industry Sector:
Adult Education Subjects:
English Learner Authorization
CLAD Certificate
Bilingual Authorization:
(Specify Language)
Pupil Personnel Services:
Supplementary Authorization/
Subject Matter Authorization:
CTC Use Only
IHE/County/District Use
Only
Issuance
Date:__________________
E-Mail Address:
________________
__________________
________________
___________________________
____________________________
__________________________ _________________________ ________________________________
Single Subject
Multiple Subject
Education Specialist
Career Technical (CTE)
Adult Education
Other:
____________________
Administrative
Pupil Personnel
Speech-Language
Pathology
Teacher Librarian
School Nurse
Other:
__________________
____________________________
FORM 41-4 (REV. 7/2019)
1
5. CHILD DEVELOPMENT PERMIT RENEWAL SELF-VERIFICATION
As the holder of a Child Development Permit (any level except the Associate Teacher Permit) you must complete a specific number of
planned and approved professional growth activities for each five-year renewal. These activities must be recorded on the Professional
Growth Plan and Record form. As the holder of a Child Development Permit choosing to self-verify completion of these requirements,
you may be subject to an audit. The Commission reserves the right to request submission of these forms for auditing purposes any
time within one year following submission of this application. If the Commission determines through its audit that you did not complete
the professional growth requirements, your permit will not be renewed and you may be subject to adverse action on other credentials
you currently hold. You must retain your Professional Growth Plan and Record form for one year following the submission of this
application.
DECLARATION:
I certify (or declare) that I have read the above and completed the following for this renewal of my Child Development Permit:
I have completed hours of professional growth activities
My Professional Growth Advisor is
Advisor’s Name Advisor’s Phone Number
6. PROFESSIONAL FITNESS QUESTIONS
Answers to the following questions are required. If you answer yes to any question, you must complete the
corresponding Professional Fitness Explanation Form.
Before granting your application, the Commission will review, at a minimum:
Federal Bureau of Investigation criminal history (rap sheet)
California Department of Justice criminal history (rap sheet)
International database of teacher misconduct maintained by the National Association of State Directors of
Teacher Education and Certification (NASDTEC)
Previous reviews by the Commission
Complaints from others
Notifications from school districts
Teacher preparation test score violations
You must disclose misconduct, even if:
It happened a long time ago
It happened in another state, federal court, military or jurisdiction outside the United States
You did not go to court and your attorney went for you
You did not go to jail or the sentence was only a fine or probation
You received a certificate of rehabilitation
Your conviction was later dismissed (even if under Penal Code section 1203.4), expunged, set aside or the
sentence was suspended
WARNING: You will be required to sign your application under penalty of perjury; by doing so you are also
stating that you understand:
That the information you provide is true and correct;
That you understand any and all instructions related to your application;
Failure to disclose any information requested is falsification of your application and the Commission may
reject or deny your application or take disciplinary action against your credential;
The Commission may reject your application if it is incomplete and it will be delayed.
__________
___________________________________________ ____________________________
FORM 41-4 (REV. 7/2019)
2
a.
Have you ever been:
dismissed or,
non-reelected or,
suspended without pay for more than ten days, or
retired, or
resigned from, or otherwise left school employment
because of allegations of misc
onduct or while allegations of misconduct were pending?
Yes No
b.
Have you ever been convicted of any felony or misdemeanor in California or any other place?
You must disclose:
all criminal convictions
misdemeanors and felonies
convictions based on a plea of no contest or nolo contendere
convictions dismissed pursuant to Penal Code Section 1203.4
driving under the influence (DUI) or reckless driving convictions
no matter how much time has passed
You do not have to disclose:
misdemeanor marijuana-related convictions that occurred more than two years prior to this application, except
convictions involving concentrated cannabis, which must be disclosed regardless of the date of such a
conviction.
infractions (DUI or reckless driving convictions are
not infractions)
Yes
No
c.
Are you currently the subject of any inquiry or investigation by any law enforcement agency or any licensing agency
in California or any other state?
Yes
No
d.
Are any criminal charges currently pending against you?
Yes No
e.
Have you ever had any credential, including but not limited to, any Certificate of Clearance, permit, credential,
license or other document authorizing public school service, revoked, denied, suspended, publicly reproved, and/or
otherwise subjected to any other disciplinary action (including an action that was stayed) in California or any other
state or place?
Yes
No
FORM 41-4 (REV. 7/2019)
3
f. Have you ever had any professional or vocational (not teaching or educational) license revoked, denied, suspended,
and/or otherwise subjected to any other disciplinary action (including an action that was stayed) in California or any
other state or place?
Yes No
7. CHILD ABUSE AND NEGLECT MANDATED REPORTING
As a documentholder authorized to work with children, it is part of my professional and ethical duty to report every
instance of child abuse or neglect known or suspected to have occurred to a child with whom I have professional contact.
I understand that I must report immediately, or as soon as practicably possible, by telephone to a law enforcement
agency or a child protective agency, and will send a written report and any evidence relating to the incident within 36
hours of becoming aware of the abuse or neglect of the child.
I understand that reporting the information regarding a case of possible child abuse or neglect to an employer, supervisor,
school principal, school counselor, coworker, or other person is not a substitute for making a mandated report to a law
enforcement agency or a child protective agency.
I understand that the reporting duties are individual and no supervisor or administrator may impede or inhibit my
reporting duties.
I understand that once I submit a report, I am not required to disclose my identity to my employer.
I understand that my failure to report an instance of suspected child abuse or neglect as required by the Child Abuse and
Neglect Reporting Act under Section 11166 of the Penal Code is a misdemeanor punishable by up to six months in jail or
by a fine of one thousand dollars ($1,000), or by both that imprisonment and fine.
I acknowledge and certify that as a documentholder, I will fulfill all the duties required of a mandated reporter.
I agree
8. EMPLOYING AGENCY INFORMATION
This section must be completed for all credential, certificate, and permit types where service is restricted to an employing agency.
County CDS Code _________________________________ School District CDS Code ______________________________
Charter School/Non-Public School or Agency/Statewide Agency Name ____________________________________________
Applications for One-year Nonrenewable Credentials, Provisional Internship Permits, Short-Term Staff Permits, Limited Assignment
Permits, and Emergency Permits (except 30-Day or Prospective Substitute Teaching Permits), must be filed through the employing
agency. Employers must have an annual Declaration of Need for Fully Qualified Educators on file with the Commission prior to the
submission of any applications for Limited Assignment or Emergency Permits.
Before submitting, please review the application for completeness:
1) Personal information with correct SSN, date of birth, and email address filled in on page 1
2) Type of credential clearly marked on page 1 (use box below for additional subject/authorization requests)
3) All Professional Fitness Questions marked Yes or No on pages 3 and 4
4) Read and agreed to your responsibilities as a mandated reporter
5) Payment (check or money order attached to the front of this form). See Credential Leaflet CL-659 for fee
schedule.
FORM 41-4 (REV. 7/2019)
4
Checks or money orders may be made payable to the Commission on Teacher Credentialing. The Commission does
not accept cash payments. All application fees are non-refundable.
Applications submitted that are incomplete or without the appropriate fee included will not be processed and will
be returned.
9. OATH AND AFFIDAVIT
*
I solemnly swear (or affirm) that I will support the Constitution of the United States of America, the Constitution of the State of
California, and the laws of the United States and the State of California. I hereby certify (or declare) under penalty of perjury
under the laws ofthe State of California that all the foregoing statements in this application are true and correct.
Date
_____________________ _________________________________________ ___________________ ________
(mm/dd/yyyy)
City
(where you sign the form)
County State
SIGNATURE OF APPLICANT __________________________________________________________________________________________
*
You must complete all portions of this section.
Comments/Additional Subject Requests:
FORM 41-4 (REV. 7/2019)
5
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APPLICATION FOR CREDENTIAL AUTHORIZING PUBLIC SCHOOL SERVICE (Form (California)

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