Where to send the application: The Agency reviews applications and makes decisions for Exemptions for:

Size: px
Start display at page:

Download "Where to send the application: The Agency reviews applications and makes decisions for Exemptions for:"

Transcription

1 BACKGROUND SCREENING Applicatin fr Exemptin AUTHORITY: In accrdance with sectin , Flrida Statutes, persns disqualified frm emplyment may be granted an exemptin frm disqualificatin. The granting f an exemptin des nt change an individual s criminal histry. It nly prvides eligibility fr emplyment in a health care setting. An individual seeking an exemptin must demnstrate by clear and cnvincing evidence that an exemptin frm disqualificatin shuld be granted. The applicatin will be reviewed and a decisin made nce all relevant dcumentatin listed belw has been received. A persn is nt eligible t apply fr an Exemptin frm Disqualificatin until: He/she has been lawfully released frm cnfinement, supervisin, r ther nnmnetary cnditin impsed by the curt fr a disqualifying misdemeanr criminal ffense; At least 3 years after he/she has been lawfully released frm cnfinement, supervisin, r ther nnmnetary cnditin impsed by the curt fr a disqualifying felny criminal ffense. He/she has cmpleted any curt-rdered fee, fine, fund, lien, civil judgment, applicatin, csts f prsecutin, trust, r restitutin as part f the judgment and sentence fr any disqualifying felny r misdemeanr in full. Persns designated as sexual predatrs, sexual ffenders r career ffenders are nt eligible fr an Exemptin frm Disqualificatin. APPLICATION CHECKLIST: The fllwing items must be included with this Applicatin fr Exemptin frm Disqualificatin: A current Level II screening was cnducted electrnically thrugh the Agency fr Health Care Administratin r the Care Prvider Backgrund Screening Clearinghuse by an apprved live scan vendr. (Fr mre infrmatin regarding Level II backgrund screenings, please visit: Arrest reprts fr all ffenses listed n the criminal histry reprt. The arrest reprt is a detailed narrative that explains the reasn fr yur arrest. Arrest reprts may be btained frm the law enfrcement (plice department, sheriff s ffice, etc.) agency that made the arrest. Curt dispsitins fr all ffenses listed n the criminal histry reprt. Curt dispsitins may be btained frm the clerk f the curt in the cunty in which yu were arrested. The dispsitin is the curt dcument that states what yu were actually sentenced fr and the cnditins f yur sentence. Signed Statement (nly needed if yu cannt btain the arrest reprt and/r curt dispsitin): Please write a detailed statement n each arrest explaining why yu were arrested. Yu must include the victim s age and relatinship t yu and the sentence yu received (prbatin, jail, prisn, etc.). If yur ffense was related t theft, please include the item(s) and the apprximate value f the item(s) stlen. Dcumentatin frm the clerk f curt and/r the arresting agency must be prvided n letterhead indicating the dcument(s) are n lnger available. Please make sure yu sign the statement.* If yu were given prbatin r parle, yu will need a letter frm the prbatin department with the fllwing infrmatin required fr each ffense: the date yu started prbatin r parle; the date yu are scheduled t terminate prbatin r parle; if yu are eligible fr early terminatin f prbatin r parle; if yu have vilated prbatin r parle; and if s, what was the vilatin. Prvide 3-5 letters f reference. One reference letter must be frm a current r mst recent emplyer n the emplyer s letterhead. Other letters must be frm individuals yu have knwn fr at least tw years thrugh cntact at the wrkplace, cmmunity activities, educatin, r training centers. Individuals prviding a letter f recmmendatin shuld include their name, address, and telephne number fr verificatin r pssible interview. Dcumentatin f rehabilitatin. Rehabilitatin includes successful cmpletin f a curt-rdered treatment r cunseling prgram, educatinal, r training certificates, prf f participatin in cmmunity activities, special recgnitin, r awards received. Page 1 f 6

2 Where t send the applicatin: The Agency reviews applicatins and makes decisins fr Exemptins fr: Send yur applicatin t: - unlicensed persnnel wrking fr a health care prvider - facility wner, administratr, r chief financial fficer - Medicaid Prvider Enrllment - Medicaid Managed Care Health Plan Backgrund Screening Unit Agency fr Healthcare Administratin 2727 Mahan Drive MS #40 Tallahassee, FL (850) The Department f Health reviews applicatins and makes decisins fr licensed and certified health care prfessinals as lng as that persn is wrking in the scpe f his r her license r certificatin. Fr mre infrmatin regarding the exemptin prcess fr licensed r certified individuals with the Department f Health, visit r by calling Page 2 f 6

3 AHCA Use Only BACKGROUND SCREENING Applicatin fr Exemptin Date Received: Date 1 st Reviewed: Date Omissins Sent: Date Appl. Cmplete: Hearing? Y N Decisin Date: AUTHORITY: In accrdance with sectin , Flrida Statutes, this applicatin is submitted fr an Exemptin frm Disqualificatin t seek emplyment in a health care setting fr which emplyment was denied due t a disqualifying criminal histry ffense. Disclsure f yur scial security number is vluntary. The Agency fr Health Care Administratin shall use such infrmatin fr purpses f internal identificatin. NOTE: The granting f an exemptin by any State Department (including this Agency) des nt clear the criminal histry. The exemptin nly prvides eligibility fr emplyment despite the presence f a disqualifying ffense(s). The exemptin nly prvides eligibility fr emplyment despite the presence f a disqualifying ffense(s). If granted, an exemptin shall be vided if yu receive a new disqualifying criminal ffense after the date the exemptin is issued. 1. PERSONAL INFORMATION Please select any f the fllwing that apply: I applied fr emplyment with a health care prvider in a psitin that des nt require licensure r certificatin (i.e. Dietary, hmemaker r cmpanin sitter, hme health aide, etc.) and must btain an exemptin befre I can wrk. I am an wner, administratr r chief financial fficer fr a health care prvider that is currently licensed r seeking licensure by the Agency. I have submitted an applicatin fr enrllment as a Medicaid Prvider. I am emplyed with a Medicaid Managed Care Health Plan. Principals f the prvider entity include any fficer, directr, billing agent, managing emplyee, r affiliated persn, r any partner r sharehlder wh has an wnership interest equal t 5 percent r mre in the prvider. NOTE: If yu are seeking an exemptin t wrk as a CNA, RN, LPN r ther licensed r certified psitin, please cntact the apprpriate licensing bard at the Department f Health. Last Name: First Name: Middle Name: Maiden Name: Mailing Phne Number: Please include Area Cde City: State: Zip: Optinal Scial Security Number: Date f Birth: mm/dd/yyyy Sex: List All Prir Names, Aliases, AKAs: Race: White Black Indian Asian r Pacific Islander Other: (INDICATE HISPANIC AS BLACK OR WHITE BASED ON SKIN COLOR) Have yu applied fr an exemptin frm disqualificatin with anther state agency? YES NO If yes, cmplete the fllwing: State Agency where exemptin request was submitted: (i.e. Department f Children and Families, Department f Health, etc.) M F Date applicatin submitted: Exemptin decisin: Date f decisin: Granted Denied Withdrawn Still under review NOTE: Even if yu have received an exemptin frm disqualificatin frm anther state agency, yu are still required t apply fr an exemptin thrugh this Agency. Prf f exemptin must be prvided with the applicatin. The Agency will take int cnsideratin any exemptin that is granted thrugh anther state agency when making a decisin. Page 3 f 6

4 2. EMPLOYMENT INFORMATION Name f Prvider where yu are emplyed r seeking emplyment: Street Phne Number: Please include Area Cde City: State: Zip: Please select the type f health care prvider fr which yu wrk r were denied emplyment due t yur criminal histry: Adult Day Care Center Health Care Clinic ICF/DD Adult Family Care Hme Health Care Services Pl Nurse Registry Assisted Living Facility Hme Health Agency Nursing Hme Cmmunity Mental Health Hme Medical Equipment Prescribed Pediatric Extended Care Crisis Stabilizatin Unit Hmemaker/Cmpanin Service Residential Treatment Facility/Center Durable Medical Equipment Hspice Other: Please select the type f psitin yu are seeking an exemptin. NOTE: Nurses, Certified Nursing Assistants and ther prfessins licensed r certified thrugh the Department f Health (DOH) must apply fr an exemptin thrugh the apprpriate licensing bard at DOH. Administratr Chief Financial Officer/ Dietary Hme Health Aide Owner / Operatr w/ 5% r mre interest Mental Health Persnnel Risk Manager Hmemaker/Cmpanin Sitter Maintenance Nursing Assistant (nn-certified)/patient Aid Relief Persn Emplyee / Staff Persn Other: 3. EMPLOYMENT HISTORY Identify the name and address f each emplyer, supervisr, address, telephne number, dates f emplyment and yur jb respnsibilities fr the last 5 years. Please explain any breaks in emplyment that exceed 3 mnths. Attach additinal sheets if necessary. Current r Mst Recent Emplyer: Emplyer: Page 4 f 6

5 Emplyer: Emplyer: Emplyer: 4. EDUCATION / TRAINING Please cmplete the fllwing and include cpies f any certificates, diplmas, and licenses if applicable. 1. What is yur highest level educatin cmpleted? Did nt cmplete high schl AA Degree Dctrate GED r equivalent BS/BA degree Other: High Schl Diplma Master s Degree 2. Are yu enrlled in r have yu cmpleted a training prgram t btain certificatin r prfessinal licensure in a health-related ccupatin? Yes N If Yes, please cmplete the fllwing: Name f Schl/Prgram Type f Training (Hme Health Aide, Nursing Assistant, etc.) Date f Training Training Cmpleted? Certificate r License Received? Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N Page 5 f 6

6 3. Are yu a licensed r certified health care prfessinal? Yes N If yes, please prvide yur license r certificate number: 4. Have yu registered fr examinatins required t btain certificatin r prfessinal licensure in a health related ccupatin? Yes N If yes, please cmplete the fllwing: Type f Exam Date Applied fr Exam Date f Exam 5. CONFIRMATION TO REQUEST AN EXEMPTION REVIEW By submitting this applicatin I frmally request an exemptin review in accrdance with sectin , Flrida Statutes. The infrmatin in this applicatin and the dcuments I have prvided are true and crrect. I understand that it is my respnsibility t prvide clear and cnvincing evidence that I will nt pse a danger t the health r safety f health care patients r their prperty. I als understand that the decisin f the Agency fr Health Care Administratin regarding this exemptin may be cntested thrugh a hearing requested under the prvisins f Chapter 120, Flrida Statutes. I understand that infrmatin and dcuments submitted in this applicatin are public recrds and shall be subject t public inspectin as prvided fr in Chapter 119, Flrida Statutes, except fr infrmatin exempted by law frm public viewing. * Pursuant t , F.S., whever knwingly makes a false statement in writing with the intent t mislead a public servant in the perfrmance f his r her fficial duty shall be guilty f a misdemeanr f the secnd degree, punishable as prvided in , F.S., r , F.S. Please Print Yur Name Signature Date Page 6 f 6

Become a Certified Nursing Assistant and Make a Difference in the Lives of Others! Applicant Name: Home Address: City: Zip Code:

Become a Certified Nursing Assistant and Make a Difference in the Lives of Others! Applicant Name: Home Address: City: Zip Code: Caring fr Our Elderly Prject 2014 Schlarship Applicatin SAU TECH Nursing Assistant Training Prgram Funded by Blue &Yu Fundatin fr a Healthier Arkansas Becme a Certified Nursing Assistant and Make a Difference

More information

Massage Therapist Licensure Application

Massage Therapist Licensure Application Flrida Bard f Massage Therapy PO Bx 6330 Tallahassee, FL 32314-6330 Web: www.flridasmassagetherapy.gv Email: inf@flridasmassagetherapy.gv Massage Therapist Licensure Applicatin Fees must be paid in the

More information

Frequently Asked Questions about the Faith A. Fields Nursing Scholarship Loan

Frequently Asked Questions about the Faith A. Fields Nursing Scholarship Loan ARKANSAS STATE BOARD OF NURSING 1123 S. University Avenue, Suite 800, University Twer Building, Little Rck, AR 72204 Phne: (501) 686-2700 Fax: (501) 686-2714 www.arsbn.rg Frequently Asked Questins abut

More information

LAW ENFORCEMENT TECHNOLOGY CREDIT BY EXAMINATION FACT SHEET Texas

LAW ENFORCEMENT TECHNOLOGY CREDIT BY EXAMINATION FACT SHEET Texas LAW ENFORCEMENT TECHNOLOGY CREDIT BY EXAMINATION FACT SHEET Texas Ri Salad Cllege, a Maricpa Cunty Cmmunity Cllege in Tempe, Arizna, is prud t annunce its Credit by Examinatin prgram in Law Enfrcement

More information

Application Fee Schedule Please check the appropriate box below. See also Additional Information starting on page 6.

Application Fee Schedule Please check the appropriate box below. See also Additional Information starting on page 6. DRIVING SCHOOL LICENSE APPLICATION N. APPLICATION DMV USE ONLY N. LICENSE Received Fee Amunt Expiratin Fee Amunt PART 1 Schl Infrmatin: l READ VEHICLE AND TRAFFIC LAW SECTION 394 AND DMV COMMISSIONER S

More information

2. Visit the Admissions section of the TCC website http://www.tcc.edu/students/admissions/. Follow steps #1-3.

2. Visit the Admissions section of the TCC website http://www.tcc.edu/students/admissions/. Follow steps #1-3. Dear Early Childcare Educatr, We are pleased t infrm yu that GrwSmart is nw accepting applicatins fr teacher schlarships fr the upcming semester. Please share the fllwing infrmatin with yur clleagues and

More information

INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR CERTIFICATE OF EXEMPTION FROM LICENSURE AS A HEALTH CARE CLINIC

INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR CERTIFICATE OF EXEMPTION FROM LICENSURE AS A HEALTH CARE CLINIC INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR CERTIFICATE OF EXEMPTION FROM LICENSURE AS A HEALTH CARE CLINIC REFERENCES: CHAPTER 400, PART X, F.S. (2006) AND FAC 59A-33.006. As prvided in s. 400.9935

More information

Application for 477 Services

Application for 477 Services An Indian Rerganizatin Act Village Under Act f Cngress June 15 th, 1935 32 Chilkat Ave. Klukwan, Alaska 99827 HC60 Bx 2207 Haines, Alaska 99827 Phne: 907-767-5505 Fax: 907-767-5408 klukwan@chilkat-nsn.gv

More information

IN THE IOWA DISTRICT COURT FOR WINNESHIEK COUNTY. Defendant, after consultation with counsel, makes the following statements:

IN THE IOWA DISTRICT COURT FOR WINNESHIEK COUNTY. Defendant, after consultation with counsel, makes the following statements: IN THE IOWA DISTRICT COURT FOR WINNESHIEK COUNTY STATE OF IOWA, ) ) CASE NO. Plaintiff, ) ) vs., ) ) Defendant. ) ) WRITTEN GUILTY PLEA AND ) WAIVER OF RIGHTS Defendant, after cnsultatin with cunsel, makes

More information

c) Be a permanent resident of the United States and the State of Florida. (A resident is

c) Be a permanent resident of the United States and the State of Florida. (A resident is THIRTEENTH JUDICIAL CIRCUIT IN AND FOR HILLSBOROUGH COUNTY (Revised 1/9/06) PROCEDURES FOR PROCESS SERVER CERTIFICATION Cmpleted Applicatins are Sub.iect t Apprpriate Public Recrds Disclsure Law Applicatins

More information

NEW FUTURES APPLICATION

NEW FUTURES APPLICATION NEW FUTURES APPLICATION Guidelines fr Applicants These schlarships will finance thse pursuing pst-secndary educatin f the fllwing types: Students wh are applying t pst-secndary vcatinal certificate prgrams,

More information

Application for Cathedral Kitchen s Culinary Arts Training Program

Application for Cathedral Kitchen s Culinary Arts Training Program Applicatin fr Cathedral Kitchen s Culinary Arts Training Prgram Cathedral Kitchen s Culinary Arts Training (CAT) prgram is an Equal Opprtunity Educatinal prgram. Enrllment is ffered n the basis f qualificatins,

More information

Applicant Prior Conviction Information for Licensing

Applicant Prior Conviction Information for Licensing Applicant Prir Cnvictin Infrmatin fr Licensing Disqualifying Penal Cde Sectins fr CAN/HHA Licensing If they have been cnvicted f any f the fllwing penal cdes listed, CNA/HHA applicants will be autmatically

More information

2015-16 Independent Verification Worksheet for HSC Students

2015-16 Independent Verification Worksheet for HSC Students 15IVHP 2015-16 Independent Verificatin Wrksheet fr HSC Students Yur applicatin was selected fr review in a prcess called verificatin. In this prcess, Temple University will be cmparing infrmatin frm yur

More information

19 th Judicial Circuit Court Appointed Attorney Application and Preference Form

19 th Judicial Circuit Court Appointed Attorney Application and Preference Form 19 th Judicial Circuit Curt Appinted Attrney Applicatin and Preference Frm Please prvide the fllwing infrmatin as a part f the applicatin and verificatin prcess fr the General Registry f Curt Appinted

More information

Early Childhood Development Services. Early Childhood Education Assistance Program. Terms and Conditions

Early Childhood Development Services. Early Childhood Education Assistance Program. Terms and Conditions Early Childhd Develpment Services Early Childhd Educatin Assistance Prgram Table f Cntents Overview... 2 Prgram Descriptin... 2 Eligibility Criteria... 3 Apprved Early Childhd Training Prgrams... 3 Prgram

More information

UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 FORM WB-DEC

UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 FORM WB-DEC UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washingtn, D.C. 20549 FORM WB-DEC DECLARATION OF ORIGINAL INFORMATION SUBMITTED PURSUANT TO SECTION 21F OF THE SECURITIES EXCHANGE ACT OF 1934 A. SUBMITTER

More information

Frequently Asked Questions About I-9 Compliance

Frequently Asked Questions About I-9 Compliance Frequently Asked Questins Abut I-9 Cmpliance What is required t verify wrk authrizatin? The basic requirement t verify wrk authrizatin is the Frm I-9. This frm is available n the HR website: http://www.fit.edu/hr/dcuments/frms/i-9.pdf

More information

Extended Major Review of Progress for Doctoral Programs

Extended Major Review of Progress for Doctoral Programs Return the cmpleted frm t: Adelaide Graduate Centre Level 6, 115 Grenfell Street SA 5005 Extended Majr Review f Prgress fr Dctral Prgrams Divisin f the Deputy Vice-Chancellr and Vice-President (Research)

More information

Loan Application for Pre- Approval

Loan Application for Pre- Approval Lan Applicatin fr Pre- Apprval Get pre-apprved fr yur hme lan financing tday by cmpleting this applicatin. Please cmplete the entire applicatin and return with the dcumentatin requested n the attached

More information

University of Texas at Tyler 2015-2016 Special Circumstances Request Independent Student

University of Texas at Tyler 2015-2016 Special Circumstances Request Independent Student University f Texas at Tyler 2015-2016 Special Circumstances Request Independent Student Student Name: ID#: Sectin I. In accrdance with Federal regulatins, student and spuse 2014 incme is used t determine

More information

3/2 MBA Application Instructions

3/2 MBA Application Instructions 3/2 MBA Applicatin Instructins IMPORTANT INFORMATION Deadlines fr admissin are psted t the 3/2 MBA website. Applicatins are encuraged t be submitted by Nvember 1 f the Junir year. Please nte that all required

More information

LOUISIANA TECH UNIVERSITY Division of Student Financial Aid Post Office Box 7925 Ruston, LA 71272

LOUISIANA TECH UNIVERSITY Division of Student Financial Aid Post Office Box 7925 Ruston, LA 71272 LOUISIANA TECH UNIVERSITY Divisin f Student Financial Aid Pst Office Bx 7925 Rustn, LA 71272 Dear Financial Aid Applicant, Accrding t yur 2011-2012 Student Aid Reprt (SAR), yu did nt include any parental

More information

Clinical Genetic Molecular Biologist Scientist Training Program. Application Procedure

Clinical Genetic Molecular Biologist Scientist Training Program. Application Procedure Clinical Genetic Mlecular Bilgist Scientist Training Prgram Applicatin Prcedure Step 1 Fill ut, print, and sign the CGMBS applicatin (see belw). Mail it directly t: Julie Fley, Educatin Crdinatr CGMBS

More information

Resident Assistant Application JOB DESCRIPTION

Resident Assistant Application JOB DESCRIPTION Requirements and Cmpensatin Resident Assistant Applicatin JOB DESCRIPTION Must have cmpleted at least 24 credit hurs at the time f emplyment. Must have a clear judicial recrd with Husing and Residential

More information

BridgeValley Community and Technical College Financial Aid Office 2015-2016 Maximum Hour Financial Aid Suspension Appeal Process

BridgeValley Community and Technical College Financial Aid Office 2015-2016 Maximum Hour Financial Aid Suspension Appeal Process BridgeValley Cmmunity and Technical Cllege Financial Aid Office 2015-2016 Maximum Hur Financial Aid Suspensin Appeal Prcess T receive financial aid administered by BridgeValley Cmmunity and Technical Cllege,

More information

FORM ADV (Paper Version) UNIFORM APPLICATION FOR INVESTMENT ADVISER REGISTRATION AND REPORT FORM BY EXEMPT REPORTING ADVISERS

FORM ADV (Paper Version) UNIFORM APPLICATION FOR INVESTMENT ADVISER REGISTRATION AND REPORT FORM BY EXEMPT REPORTING ADVISERS APPENDIX A FORM ADV (Paper Versin) UNIFORM APPLICATION FOR INVESTMENT ADVISER REGISTRATION AND REPORT FORM BY EXEMPT REPORTING ADVISERS Frm ADV: General Instructins Read these instructins carefully befre

More information

OCEAN REEF PUBLIC SAFETY WELCOME CENTER BUSINESS REQUIREMENTS AND REGULATIONS PACKAGE

OCEAN REEF PUBLIC SAFETY WELCOME CENTER BUSINESS REQUIREMENTS AND REGULATIONS PACKAGE OCEAN REEF PUBLIC SAFETY WELCOME CENTER BUSINESS REQUIREMENTS AND REGULATIONS PACKAGE The Package includes: Business Requirements t Register Cntractrs Rules Prices O.R.C.A. I.D. Cards Requirements Day

More information

Master of Education in Organizational Leadership PROGRAM APPLICATION

Master of Education in Organizational Leadership PROGRAM APPLICATION Master f Educatin in Organizatinal Leadership PROGRAM APPLICATION Applicatin Submissin Prcess: Submit the fllwing t the Center fr Educatinal Leadership: Prgram applicatin Experience Verificatin frm Tw

More information

o o 2) Program Rewards

o o 2) Program Rewards 1) T qualify fr the American Red Crss High Schl Leadership Prgram (referred t as Prgram), each student (referred t as Member) is asked t cmplete the fllwing requirements: a. Cmplete an nline prfile at

More information

insurers cannot deny coverage for patients with preexisting conditions or because an insured got sick;

insurers cannot deny coverage for patients with preexisting conditions or because an insured got sick; The Affrdable Care Act Health Insurance Respnsibilities f Large, Midsize & Small Emplyers; Buying Insurance n the Individual Health Insurance Marketplace and the Small Business Health Optins Prgram Intrductin:

More information

Information Bulletin PT 204/09.15

Information Bulletin PT 204/09.15 Infrmatin Bulletin PT 204/09.15 Operatr Accreditatin fr Limusine Services What is peratr accreditatin? The Transprt Operatins (Passenger Transprt) Act 1994 requires peratrs f public passenger services

More information

Instructions for Completing the Fall 2014-Spring 2015 Application for Admission

Instructions for Completing the Fall 2014-Spring 2015 Application for Admission Instructins fr Cmpleting the Fall 2014-Spring 2015 Applicatin fr Admissin 1. Please type r print all entries made n the applicatin. Remember t sign the applicatin. Incmplete applicatins cannt be cnsidered.

More information

TUITION DISCOUNT PROGRAM FOR THE SCHOOL OF HEALTH SCIENCES AND PRACTICE

TUITION DISCOUNT PROGRAM FOR THE SCHOOL OF HEALTH SCIENCES AND PRACTICE TUITION DISCOUNT PROGRAM FOR THE SCHOOL OF HEALTH SCIENCES AND PRACTICE Date: Nvember 5, 2014 Supersedes: Graduate Schl Educatin Benefits, HR.314, dated 5/8/2001 References: Nne. I. PURPOSE T establish

More information

Woodstock Multimedia, INC. Software/Hardware Usage Policy

Woodstock Multimedia, INC. Software/Hardware Usage Policy Wdstck Multimedia, INC. Sftware/Hardware Usage Plicy POLICY PURPOSE The purpse f the Wdstck Multimedia, INC. Sftware / Hardware Usage Plicy is t ensure that Wdstck Multimedia, INC. emplyees are prperly

More information

STUDENT VETERAN BENEFIT CHECKLIST For POST 9/11 GI BILL AND SELECTIVE RESERVE EDUCATIONAL PROGRAMS 1606 & 1607

STUDENT VETERAN BENEFIT CHECKLIST For POST 9/11 GI BILL AND SELECTIVE RESERVE EDUCATIONAL PROGRAMS 1606 & 1607 Financial Aid, Schlarships, Veterans and Fster Yuth Prgrams 6201 Winnetka Avenue, Wdland Hills CA 91371-0002 Veterans: (818) 710-3316 ext 3316 FAX: (818) 704-8221 www.piercecllege.edu/ffices/financial_aid/veterans.asp

More information

MASSAGE THERAPY LICENSE

MASSAGE THERAPY LICENSE Guidelines fr MASSAGE THERAPY LICENSE City f Mrhead 500 Center Avenue, PO Bx 779 Mrhead, MN 56560-0799 Phne: 218.299.5304 Fax: 218.299.5306 cityclerk@ci.mrhead.mn.us Mrhead City Cde, 2-6C: Massage Enterprise

More information

EMERGENCY MEDICAL TECHNICIAN/PARAMEDIC CERTIFICATE LEARNING PROGRAM #133

EMERGENCY MEDICAL TECHNICIAN/PARAMEDIC CERTIFICATE LEARNING PROGRAM #133 SUPPLEMENTAL APPLICATION FOR ADMISSION Fall 2016 r Spring 2017 ENTRY APPLICATION INFORMATION and INSTRUCTIONS Applicatin Deadline: Fr Fall 2016 Deadline is April 15, 2016 Fr Spring 2017 Deadline is Octber

More information

City of Newburgh DEPARTMENT OF PLANNING & DEVELOPMENT City Hall 83 Broadway Newburgh, New York 12550 www.cityofnewburgh-ny.gov

City of Newburgh DEPARTMENT OF PLANNING & DEVELOPMENT City Hall 83 Broadway Newburgh, New York 12550 www.cityofnewburgh-ny.gov City f Newburgh City Hall 83 Bradway Newburgh, New Yrk 12550 www.cityfnewburgh-ny.gv Hmewner Emergency Repair Prgram Applicatin 2015-2016 Page 1 f 9 06/01/2016 City f Newburgh City Hall 83 Bradway Newburgh,

More information

FINANCIAL OPTIONS. 2. For non-insured patients, payment is due on the day of service.

FINANCIAL OPTIONS. 2. For non-insured patients, payment is due on the day of service. FINANCIAL OPTIONS 1. Fr thse patients wh carry dental insurance, all c-payments are due n date f service. We will file yur claim as a service t yu, and will d ur very best t maximize yur benefits. We accept

More information

NHVAS Mass Management Spot Check Checklist

NHVAS Mass Management Spot Check Checklist Legal Entity Name f NHVAS Operatr: DTMR Representative: Lcatin: NHVAS Mass Management Spt Check Checklist Spt Check Date: Spt Check Number: DMS Number: 540/ The fllwing surces f evidence have been identified

More information

Inspired Leaders Principal Licensure Program PROGRAM APPLICATION

Inspired Leaders Principal Licensure Program PROGRAM APPLICATION Inspired Leaders Principal Licensure Prgram PROGRAM APPLICATION Applicatin Submissin Prcess: Submit the fllwing t the Center fr Educatinal Leadership: Prgram applicatin Experience Verificatin Frm Tw Current

More information

CURRENT COLLEGE STUDENT SCHOLARSHIP 2015 AWARD REGULATIONS

CURRENT COLLEGE STUDENT SCHOLARSHIP 2015 AWARD REGULATIONS CURRENT COLLEGE STUDENT SCHOLARSHIP 2015 AWARD REGULATIONS ELIGIBILITY/LIMITATIONS FOR SCHOLARSHIP AWARD Current cllege student applicant and spnsr must meet the fllwing eligibility requirements: 1. Applicant

More information

TRAINING PLAN FOR STEM OPT STUDENTS

TRAINING PLAN FOR STEM OPT STUDENTS Adapted by UW Madisn (and inspired by the University f Michigan) frm the fllwing surce: https://www.ice.gv/sites/default/files/dcuments/dcument/2016/i983instructins.pdf Cmpleting the Frm I 983 TRAINING

More information

BLUE RIDGE COMMUNITY AND TECHNICAL COLLEGE BOARD OF GOVERNORS

BLUE RIDGE COMMUNITY AND TECHNICAL COLLEGE BOARD OF GOVERNORS BLUE RIDGE COMMUNITY AND TECHNICAL COLLEGE BOARD OF GOVERNORS SERIES: 1 General Rules RULE: 17.1 Recrd Retentin Scpe: The purpse f this rule is t establish the systematic review, retentin and destructin

More information

Supporting original research in the Canadian capital markets

Supporting original research in the Canadian capital markets Canadian Securities Institute Research Fundatin PhD Schlarship Applicatin Frm Supprting riginal research in the Canadian capital markets CSI OBJECTIVE The Canadian Securities Institute Research Fundatin

More information

Baltimore County Retired School Personnel Association, Inc. P. O. Box 44016 Nottingham, MD 21236 410-847-9700 www.bcrspa.org

Baltimore County Retired School Personnel Association, Inc. P. O. Box 44016 Nottingham, MD 21236 410-847-9700 www.bcrspa.org Baltimre Cunty Retired Schl Persnnel Assciatin, Inc. P. O. Bx 44016 Nttingham, MD 21236 410-847-9700 www.bcrspa.rg BCRSPA & WEBCO MEMORIAL SCHOLARSHIP APPLICATION 2015-2016 Seven Memrial Schlarships f

More information

Cell Phone & Data Access Policy Frequently Asked Questions

Cell Phone & Data Access Policy Frequently Asked Questions Cell Phne & Data Access Plicy Frequently Asked Questins 1. Wh is eligible fr a technlgy allwance? First and fremst, the technlgy allwance is fr the benefit f the University, rather than fr the cnvenience

More information

Student Requirements

Student Requirements Cntinuing Educatin: Allied Health Prgrams Student Requirements Desired Class Date Name Address City Phne Email Alt Phne CEQ Zip STAFF VERIFICATION: DATE: COMMENTS: PROGRAM (check ne): Dental Assistant

More information

THE CITY UNIVERSITY OF NEW YORK IDENTITY THEFT PREVENTION PROGRAM

THE CITY UNIVERSITY OF NEW YORK IDENTITY THEFT PREVENTION PROGRAM THE CITY UNIVERSITY OF NEW YORK IDENTITY THEFT PREVENTION PROGRAM 1. Prgram Adptin The City University f New Yrk (the "University") develped this Identity Theft Preventin Prgram (the "Prgram") pursuant

More information

Guidance for Law Enforcement Regarding The Medical Use of Marijuana Online System ( MMJ Online System ) Updated April 15, 2015

Guidance for Law Enforcement Regarding The Medical Use of Marijuana Online System ( MMJ Online System ) Updated April 15, 2015 CHARLES D. BAKER Gvernr KARYN E. POLITO Lieutenant Gvernr The Cmmnwealth f Massachusetts Executive Office f Health and Human Services Department f Public Health Bureau f Health Care Safety and Quality

More information

ONLINE MASTERS OF JURISPRUDENCE IN GLOBAL FOOD LAW (M.J.) PROGRAM APPLICATION FOR ADMISSION

ONLINE MASTERS OF JURISPRUDENCE IN GLOBAL FOOD LAW (M.J.) PROGRAM APPLICATION FOR ADMISSION ONLINE MASTERS OF JURISPRUDENCE IN GLOBAL FOOD LAW (M.J.) PROGRAM APPLICATION FOR ADMISSION Please see ur web site, www.law.msu.edu/llm/glbalfdlaw fr admissin requirements. After yur applicatin is cmplete

More information

Caregiver Background Check and/or Criminal History Record Check Statement of Understanding Form

Caregiver Background Check and/or Criminal History Record Check Statement of Understanding Form Caregiver Backgrund Check and/r Criminal Histry Recrd Check Statement f Understanding Frm Wiscnsin Indianhead Technical Cllege students accepted in the prgrams listed belw are required t have Caregiver

More information

FIREFIGHTER HEART AND CIRCULATORY MALFUNCTION BENEFITS PROGRAM STANDARD OPERATING GUIDELINES Approved by the DOLA Executive Director July 1, 2014

FIREFIGHTER HEART AND CIRCULATORY MALFUNCTION BENEFITS PROGRAM STANDARD OPERATING GUIDELINES Approved by the DOLA Executive Director July 1, 2014 FIREFIGHTER HEART AND CIRCULATORY MALFUNCTION BENEFITS PROGRAM STANDARD OPERATING GUIDELINES Apprved by the DOLA Executive Directr July 1, 2014 Prgram Overview: As f July 1, 2014, the Department f Lcal

More information

Diagnostic Medical Sonography Program

Diagnostic Medical Sonography Program Diagnstic Medical Sngraphy Prgram Advanced Technical Certificate Spring 2017 Applicatin INSTRUCTIONS: Applicants are t fill in all required infrmatin and fllw the instructins as indicated in each sectin

More information

Maricopa Skill Center. Nursing Assistant Program

Maricopa Skill Center. Nursing Assistant Program Maricpa Skill Center Nursing Assistant Prgram Infrmatin/Applicatin Packet Prgram Overview The Nurse Assistant is a 150 hur prgram f study designed t intrduce the student t basic cncepts f wrking in the

More information

Application Submission Checklist To Mutual of Omaha For Medicare Supplement Coverage NEW YORK

Application Submission Checklist To Mutual of Omaha For Medicare Supplement Coverage NEW YORK Mutual f Omaha Insurance Cmpany P.O. Bx 3608 Omaha, Nebraska 68103-3608 Applicatin Submissin Checklist T Mutual f Omaha Fr Medicare Supplement Cverage NEW YORK THIS APPLICATION MUST BE USED TO WRITE MUTUAL

More information

Asphalt Contractors Association of Florida ---- 2016 FAS Trade &/or Vocational School Scholarship Application

Asphalt Contractors Association of Florida ---- 2016 FAS Trade &/or Vocational School Scholarship Application Asphalt Cntractrs Assciatin f Flrida ---- 2016 FAS Trade &/r Vcatinal Schl Schlarship Applicatin Cntact infrmatin: ACAF Schlarship Prgram Asphalt Cntractrs Assciatin f Flrida, Inc. 1007 E. Dest Park Drive,

More information

Notice of Protection Provided by Utah Life and Health Insurance Guaranty Association

Notice of Protection Provided by Utah Life and Health Insurance Guaranty Association Ntice f Prtectin Prvided by Utah Life and Health Insurance Guaranty Assciatin This ntice prvides a brief summary f the Utah Life and Health Insurance Guaranty Assciatin ("the Assciatin") and the prtectin

More information

Skrill Merchant Services Application Form

Skrill Merchant Services Application Form Skrill Merchant Services Applicatin Frm Skrill Merchant Services Applicatin Frm (the Applicatin ) shuld be signed by r n behalf f the Merchant. It is very imprtant that the Merchant has read the Applicatin

More information

Post-Baccalaureate Certificate Programs

Post-Baccalaureate Certificate Programs Pst-Baccalaureate Certificate Prgrams Certificate prgrams benefit students and/r interest by prviding greater flexibility and brader training in areas related t the students' majr fields and making thse

More information

Class A School Psychometry: (Certification Only Program)

Class A School Psychometry: (Certification Only Program) Fr Additinal Infrmatin, Cntact: Dr. Stephanie Crcran Schl Psychmetry Advisr crcran@uab.edu Rm 232R Educatin Building Class A Schl Psychmetry: (Certificatin Only Prgram) Requirements & Prgram Checklist

More information

Financial Aid Summary: Get Money for College

Financial Aid Summary: Get Money for College Financial Aid Summary: Get Mney fr Cllege Whether yu're enrlling in cllege fr the first time r returning t schl after a perid f time ff, yu shuld apply fr federal student aid. Federal student aid frm the

More information

Tree Permit Process Intake: (A) (B) (C) (D) (A combination of checklists may be applicable depending on the scope of work) Review:

Tree Permit Process Intake: (A) (B) (C) (D) (A combination of checklists may be applicable depending on the scope of work) Review: Tree Permit Prcess Intake: 1. Applicants may btain the Tree Permit Applicatins frm the Envirnmental Resurces Divisin in the Planning and Zning Department lcated at 444 SW 2 nd Avenue, 3 rd Flr, Miami,

More information

Heythrop College Disciplinary Procedure for Support Staff

Heythrop College Disciplinary Procedure for Support Staff Heythrp Cllege Disciplinary Prcedure fr Supprt Staff Intrductin 1. This prcedural dcument des nt apply t thse academic-related staff wh are mentined in the Cllege s Ordinance, namely the Librarian and

More information

Skrill Merchant Services Application Form

Skrill Merchant Services Application Form Skrill Merchant Services Applicatin Frm Skrill Merchant Services Applicatin Frm (the Applicatin ) shuld be signed by r n behalf f the Merchant. It is very imprtant that the Merchant has read the Applicatin

More information

All applicants and listed vendors must submit a criminal background check valid

All applicants and listed vendors must submit a criminal background check valid AMENDMENT TO APPLICATION Receipt # Receipt # Date Submitted Date Submitted Amunt paid Amunt paid COMMERCIAL VENDOR APPLICATION PEDDLING, SOLICITING, SPECIAL EVENT VENDOR, VENDOR AT ATHLETIC EVENT Chapter

More information

Practical Nursing Program

Practical Nursing Program Practical Nursing Prgram Frnt Range Cmmunity Cllege Bulder Campus 8/5/2014 Vlume 1, Issue 1 YOU CAN SEE YOUR FUTURE FROM HERE Enrllment and acceptance int the cmpetitive Practical Nursing prgram Table

More information

Maryland General Service (MGS) Area 29 Treatment Facilities Committee (TFC) TFC Instructions

Maryland General Service (MGS) Area 29 Treatment Facilities Committee (TFC) TFC Instructions Maryland General Service (MGS) Area 29 Treatment Facilities Cmmittee (TFC) TFC Instructins Lve And Service Facility Presentatin t Patients We are frm Alchlics Annymus (AA), fr AA, and ur service is fr

More information

2015 AP Test Fee Program for Low-Income Students Procedures and Requirements

2015 AP Test Fee Program for Low-Income Students Procedures and Requirements Cntents: 1. Overview 2. Requirements fr Schls 3. Student Eligibility Criteria 4. AP Test Fee Prgram Summary and Assurances Frm 1. Overview The Tennessee Department f Educatin (TDOE) will use funds frm

More information

Care Plan Oversight. Home Health Certification. July 23, 2014. Agenda

Care Plan Oversight. Home Health Certification. July 23, 2014. Agenda Care Plan Oversight Hme Health Certificatin July 23, 2014 Agenda Care Plan Oversight Why We Are Prviding the Educatin Prcedure cdes Descriptin f Services Wh Can Perfrm Frequency f Services Face-t-Face

More information

2016-17 Independent Verification Worksheet for HSC Students

2016-17 Independent Verification Worksheet for HSC Students 16IVHP 2016-17 Independent Verificatin Wrksheet fr HSC Students Yur applicatin was selected fr review in a prcess called verificatin. In this prcess, Temple University will be cmparing infrmatin frm yur

More information

Connecticut Parenting Educator Credential Application Information

Connecticut Parenting Educator Credential Application Information Cnnecticut Parenting Educatr Credential Applicatin Infrmatin Charter Oak State Cllege, 55 Paul J. Manafrt Drive, New Britain, CT 06053-2142 -----------------------------------------------------------------------------------------------------------

More information

Connecticut State Department of Education 2014-15 School Health Services Information Survey

Connecticut State Department of Education 2014-15 School Health Services Information Survey Cnnecticut State Department f Educatin 2014-15 Schl Health Services Infrmatin Survey General Directins fr Cmpletin by Schl Nurse Crdinatr/Supervisr This Schl Health Services Infrmatin Survey was designed

More information

San Diego One-Stop Career Center Network PY 2011/2012 Revised June 2011

San Diego One-Stop Career Center Network PY 2011/2012 Revised June 2011 San Dieg One-Stp Career Center Netwrk PY 2011/2012 Revised June 2011 ADULT AND DISLOCATED WORKER PERFORMANCE POLICY 1. WIA requires a cmprehensive accuntability system t determine the effectiveness f services

More information

FAFSA / DREAM ACT COMPLETION PROGRAM AGREEMENT

FAFSA / DREAM ACT COMPLETION PROGRAM AGREEMENT FAFSA / DREAM ACT COMPLETION PROGRAM AGREEMENT If using US Pstal Service, please return t: Califrnia Student Aid Cmmissin Prgram Administratin & Services Divisin ATTN: Institutinal Supprt P.O. Bx 419028

More information

SCHOLARSHIP APPLICATION

SCHOLARSHIP APPLICATION Assciatin f State Dam Safety Officials UNDERGRADUATE SCHOLARSHIP APPLICATION SUBMIT APPLICATION AND ATTACHMENTS POSTMARKED BY MARCH 31, 2016 TO: Assciatin f State Dam Safety Officials 239 S. Limestne Lexingtn,

More information

Personal Data Security Breach Management Policy

Personal Data Security Breach Management Policy Persnal Data Security Breach Management Plicy 1.0 Purpse The Data Prtectin Acts 1988 and 2003 impse bligatins n data cntrllers in Western Care Assciatin t prcess persnal data entrusted t them in a manner

More information

Master of Science in Accounting (MSA) Application Instructions

Master of Science in Accounting (MSA) Application Instructions Master f Science in Accunting (MSA) Applicatin Instructins Befre submitting yur applicatin, please read these instructins carefully. Deadlines fr admissin are psted t the GAP website. Separate deadlines

More information

Chabot College Nursing Application Process Advanced Standing/Transfer/LVN s/program Re-Admission

Chabot College Nursing Application Process Advanced Standing/Transfer/LVN s/program Re-Admission Chabt Cllege Nursing Applicatin Prcess Advanced Standing/Transfer/LVN s/prgram Re-Admissin Step 1 A Chabt Cllege Applicatin fr AdmissinĀ¹ must be submitted t the cllege. This applicatin can be submitted

More information

Process for Responding to Privacy Breaches

Process for Responding to Privacy Breaches Prcess fr Respnding t Privacy Breaches 1. Purpse 1.1 This dcument sets ut the steps that ministries must fllw when respnding t a privacy breach. It must be read in cnjunctin with the Infrmatin Incident

More information

IMPORTANT INFORMATION ABOUT MEDICAL CARE FOR YOUR WORK-RELATED INJURY OR ILLNESS

IMPORTANT INFORMATION ABOUT MEDICAL CARE FOR YOUR WORK-RELATED INJURY OR ILLNESS IMPORTANT INFORMATION ABOUT MEDICAL CARE FOR YOUR WORK-RELATED INJURY OR ILLNESS MEDICAL PROVIDER NETWORK (MPN) NOTIFICATION If yu are injured at wrk, Califrnia Law requires yur emplyer t prvide and pay

More information

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM. State of Colorado

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM. State of Colorado Page 1 f5 Taraet Grup Targeted case management services will be prvided t alchl r ther drug dependent Medicaid clients wh need assistance in btaining necessary scial educatinal vcatinal and ther services

More information

Extended Deadline is Friday, April 10th! Health Career Exploration Symposium

Extended Deadline is Friday, April 10th! Health Career Exploration Symposium Health Career Explratin Sympsium Explring the Pssibilities in Healthcare An intensive day f explratin and hands-n immersin in health careers Thursday, June 25, 2015 8:00AM-5:30PM Lcatin: Technical Cllege

More information

The Ohio Board of Regents Credit When It s Due process identifies students who

The Ohio Board of Regents Credit When It s Due process identifies students who Credit When It s Due/ Reverse Transfer FAQ fr students Ohi is participating in a natinal grant initiative, Credit When It s Due, designed t implement reverse-transfer, which is a prcess t award assciate

More information

NextGenJustice Florida attorneys have prepared the following Frequently Asked Questions to help you with your uncontested divorce.

NextGenJustice Florida attorneys have prepared the following Frequently Asked Questions to help you with your uncontested divorce. NextGenJustice Flrida attrneys have prepared the fllwing Frequently Asked Questins t help yu with yur uncntested divrce. Frequently asked questins abut yur uncntested Flrida divrce: Q. Hw lng will my divrce

More information

Major Review of Progress for Masters by Research Programs

Major Review of Progress for Masters by Research Programs Return the cmpleted frm t the Adelaide Graduate Centre Level 6, 115 Grenfell Street SA 5005 Majr Review f Prgress fr Masters by Research Prgrams Divisin f the Deputy Vice-Chancellr and VicePresident (Research)

More information

PARALEGAL ASSOCIATION OF CENTRAL OHIO ( PACO ) P.O. Box 15182 Columbus, Ohio 43215-0182

PARALEGAL ASSOCIATION OF CENTRAL OHIO ( PACO ) P.O. Box 15182 Columbus, Ohio 43215-0182 PARALEGAL ASSOCIATION OF CENTRAL OHIO ( PACO ) P.O. Bx 15182 Clumbus, Ohi 43215-0182 TWO $750 SCHOLARSHIPS AVAILABLE FOR PARALEGAL STUDIES STUDENTS IN THE CENTRAL OHIO AREA Schlarship applicatin packets

More information

INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED.

INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED. Dear Prspective Student, Cntinuing Educatin Allied Health Thank yu fr yur interest in the Electrcardigraphy Telemetry Technician Certificate Prgram at Cllege f the Mainland. Cnsideratin fr acceptance int

More information

Military: Exemptions for Texas Veterans (Hazlewood Exemption) FAQs

Military: Exemptions for Texas Veterans (Hazlewood Exemption) FAQs Military: Exemptins fr Texas Veterans (Hazlewd Exemptin) FAQs What charges are cvered? What charges are nt cvered? Des the Hazlewd Act cver teacher certificatin fees? Des the Hazlewd Act cver credit by

More information

Occupational Therapy

Occupational Therapy Health Prfessins: Occupatinal Therapy Overview f Prfessin Pre-Requisites Applicatin Prcess Timeline Admissin Exam- GRE Additinal Requirements Overview f OT Schl Imprtant Websites Overview f Prfessin: (surce:

More information

Hartford Seminary s. Online Application Instructions

Hartford Seminary s. Online Application Instructions Hartfrd Seminary s Online Applicatin Instructins Hartfrd Seminary is pleased t annunce that nline applicatin is nw pssible fr mst f ur prgrams as fllws: Dctr f Ministry: Use nline applicatin Master f Arts:

More information

Associate of Science (AS) Professional Nursing Degree Program

Associate of Science (AS) Professional Nursing Degree Program Overview Assciate f Science (AS) Prfessinal Nursing Degree Prgram The Prfessinal Nursing (NPRO) Prgram at Minneaplis Cmmunity & Technical Cllege (MCTC) is a selective admissin prgram (yu must apply, meet

More information

Safety in Practice Compliance and Risk Assessment Procedure March, 2016

Safety in Practice Compliance and Risk Assessment Procedure March, 2016 Safety in Practice Cmpliance and Risk Assessment Prcedure Safety in Practice Cmpliance and Risk Assessment Prcedure March, 2016 Cntents 1 Objectives... 2 2 Scpe... 2 3 Safety in Practice Cmpliance and

More information

LPN to ADN Bridge Program

LPN to ADN Bridge Program LPN t ADN Bridge Prgram Frnt Range Cmmunity Cllege Bulder Campus 8/5/2014 Vlume 1, Issue 1 YOU CAN SEE YOUR FUTURE FROM HERE Enrllment and acceptance int the cmpetitive LPN-ADN Nursing prgram LPN ADN Nursing

More information

COMPREHENSIVE SAFETY ASSESSMENT INSTRUCTIONS for STUDY ABROAD PROGRAMS

COMPREHENSIVE SAFETY ASSESSMENT INSTRUCTIONS for STUDY ABROAD PROGRAMS COMPREHENSIVE SAFETY ASSESSMENT INSTRUCTIONS fr STUDY ABROAD PROGRAMS Belw is a list f items t address and questins that need t be addressed in the cmprehensive safety assessment. In additin t the safety

More information

PUBLIC SERVICE LOAN FORGIVENESS (PSLF): EMPLOYMENT CERTIFICATION FORM

PUBLIC SERVICE LOAN FORGIVENESS (PSLF): EMPLOYMENT CERTIFICATION FORM PUBLIC SERVICE LOAN FORGIVENESS (PSLF): EMPLOYMENT CERTIFICATION FORM OMB N. 1845-0110 Frm Apprved Exp. Date 12/31/2017 William D. Frd Federal Direct Lan (Direct Lan) Prgram WARNING: Any persn wh knwingly

More information

Name: (Last) (First) (Middle) Other names used since the age of 18 (maiden name, aliases): Residence Address: City Zip Code (PO Boxes not accepted)

Name: (Last) (First) (Middle) Other names used since the age of 18 (maiden name, aliases): Residence Address: City Zip Code (PO Boxes not accepted) Nrth Carlina Department f Insurance Bail Bndsman/Bail Bnd Runner License Applicatin Please check nly ne type f license: Prfessinal Bail Bndsman -$263.00 Surety Bndsman -$263.00 Bail Bnd Runner -$183.00

More information