We have enclosed the instructions and forms for you to complete and information regarding the minimum requirements for listed family homes.

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "We have enclosed the instructions and forms for you to complete and information regarding the minimum requirements for listed family homes."

Transcription

1 Dear Potential Relative Child Care Provider, The Texas Workforce Commission adopted a ruling which states a relative providing child care in the relative s residence must be listed with the Texas Department of Family Protective Services (DFPS) to be an eligible relative provider with Workforce Solutions Northeast Texas. Relative providers must provide Workforce Solutions Northeast Texas with a copy of a listing permit issued by DFPS before child care assistance can be approved. We have enclosed the instructions and forms for you to complete and information regarding the minimum requirements for listed family homes. Please follow the instructions exactly to assure that your listing application is processed. DFPS has stated that processing could take 45 days or more. As soon as you receive your listing certificate from DFPS, please mail or fax us a copy. At that time, we will mail you our Relative Provider eligibility packet to complete and return. If you have any questions, please contact our office. Respectfully, Workforce Solutions Northeast Texas Child Care Services

2 MAILING INSTRUCTIONS FOR LISTED FAMILY HOME APPLICATIONS 1. Mail application (Form 2986-Listing Request), Background Checks (Form 2971) & a copy of your check or money order to the following address: Texas Dept. of Family & Protective Services Attn: Debra Goza, Listed Family Home Technician Child Care Licensing 8700 N. Stemmons Frwy. Dallas, TX A background check is required for everyone 14 years and older in your home. Fill out one section for each individual. Debra will contact you either by phone or letter and give you an operation number. Do not mail payment to Austin prior to obtaining the operation number. This number must be printed on your check and your fee payment form or the money will not be credited to your (child care) operation. 2. Mail payment (check or money order) (NO CASH) along w/fee schedule (Form 2988) to the following address or use the enclosed envelope after obtaining the operation number and putting the operation number on your fee payment form and payment: Texas Dept. of Protective & Regulatory Services Licensing Fee Accounting Division E-672 P. O. Box Austin, TX Enclosures: The other information included in this packet is useful information to a child care provider. Also included are the laws associated with child care.

3 Requirements for Listed Family Homes The Texas Workforce Commission requires that relatives who care for a child in the relative s home be listed with the Department of Family and Protective Services (DFPS) in order to be eligible to be reimbursed for providing child care services. Once listed with DFPS, you will be required to comply with DFPS rules and all provisions of Chapter 42 of the Texas Human Resources Code (the child care licensing law) that apply to listed family homes. Additionally, information about your listed family home will be posted on the DFPS Web site and you could receive inquiries from individuals needing a caregiver for their child. As a listed family home, you must be aware of and comply with the DFPS requirements for listed family homes outlined below. The following caregivers are required to list with DFPS: An individual at least 18 years old who provides care for compensation for three or fewer children, ages birth through 13 years, who are unrelated to the caregiver. The care is provided for at least four hours a day, three or more days a week, and for more than nine consecutive weeks. Total number of children in care: The total number of children in care, including children related to the caregiver, may not exceed 12*. A caregiver who is subject to regulation as a listed family home and wishes to care for more than three children unrelated to the caregiver must instead become a registered child care home. *Note: Your Local Workforce Development Board may have a local policy limiting the number of subsidized children you can care for. Annual Fee Renewal: You are required to pay an annual fee of $20. DFPS will notify you when your annual fee is due. Failure to pay the annual fee will result in revocation of the listing permit and you will not be allowed to receive a subsidy for providing child care services. There are no additional fees for the background check requirements described below. Background Check Requirements: You must continue to submit background check information, using the Request for Criminal History and Central Registry Check, Form 2971, for the following: Individuals who regularly or frequently work or live in the home and are turning 14 years of age; and New individuals regularly or frequently working or living in the home. WD Letter 50-07, Attachment 3

4 Background check information for these individuals must be submitted within two business days after the individual turns 14 years of age or is newly present in the home. You must resubmit background check requests for all individuals once every 24 months after you first submit an individual s name to DFPS. Required Notification to DFPS: You are required to notify DFPS if you move or close your family home. WD Letter 50-07, Attachment 2 2

5 Instructions for Relative Child Care Providers on Completing Required Texas Department of Family and Protective Services Forms General Instructions: You must submit the following forms to the Texas Department of Family and Protective Services (DFPS) Local Child Care Licensing Office: Listing Request, Form 2986; and Request for Criminal History and Central Registry Check, Form You must submit the following form, along with a $20 application fee, to the DFPS Accounting Division in Austin, Texas (address provided in detailed instructions below): Child Care Fee Schedule, Form The forms must be filled out completely. Any form not fully completed will be returned to you, and DFPS will not process your application until all of the requested information is provided. Listing Request, Form 2986 General Instructions: Do not leave any blanks. Write none, not applicable, or NA if an item does not apply. If the question is a required yes or no question, check either Yes or No; do not leave the answer blank. Your Information: Provide your name, address (including mailing address), telephone number, date of birth, Social Security number, and Texas Driver s License number. Note: For Social Security number and Texas Driver s License number, indicate if you do not have a Social Security number or a Texas Driver s License, or if your driver s license is out-ofstate. 1. List each individual 14 years of age or older who will regularly or frequently be present, staying, or working at the home while the children are in care. Important: Submit the Request for Criminal History and Central Registry Check, Form 2971, on yourself, and all individuals listed in question #1 of the Listing Request, Form Check either Yes or No if other individuals not listed in #1 will assist you in caring for children in the home. If Yes, provide each individual s name, address, telephone number, Social Security number, and Texas Driver s License number (if available). Add these individuals to the Request for Criminal History and Central Registry Check, Form Important: Although other individuals may assist you in caring for an eligible child, the Texas Workforce Commission and the Local Workforce Development Board cannot reimburse those individuals. Additionally, you must be present in the home when those individuals provide care. WD Letter 50-07, Attachment 2

6 3A. Check Yes to indicate that you are requesting to be listed in order to receive a federal child care subsidy. 3B-C. Indicate whether you are caring for children who are not related to you and the number of related and unrelated children you are caring for or intend to care for. 4. Check either Yes or No if you have ever been licensed, registered, or listed as a child care provider by any agency of the State of Texas. If Yes, provide information on your previous license or registration. 5. Information for the DFPS Web site is required. Information regarding your operation and its compliance history will be posted on the DFPS Web site. However, the information requested in Services Offered and Directions to Location under this question is optional. Signature and Date: You must sign and date the form. Mailing Instructions: Mail this form to your DFPS Local Licensing Office. Texas Workforce Center staff can provide you a list of addresses for DFPS Local Child Care Licensing Offices. Request for Criminal History and Central Registry Check, Form 2971 General Instructions: Do not leave any blanks. Write none, not applicable, or N/A if an item does not apply. If the question is a required yes or no question, check either Yes or No; do not leave the answer blank. Your Information: Provide your name as the Operation Name. This must be the same name as appears on the Listing Request, Form Write N/A for the Operation Number. This number will be provided to you upon approval of your listing permit by DFPS. Provide the street address, mailing address, county, and telephone number that you provided on the Listing Request, Form Signature and Date: You must sign and date this form. Individuals for Whom a Background Check Is Requested: Complete information for yourself and each individual listed in questions #1 and #2 on the Listing Request, Form Note: This form provides the space necessary for information on up to three individuals. Fill out as many copies of page two as necessary if there are more than three individuals requiring a background check. Indicate that this is an Initial background check. Provide the Social Security number and Texas Driver s License or other ID number. Provide the individual s name as it appears on the Listing Request, Form Provide the individual s street address, county, and telephone number. Provide the individual s date of birth and gender. WD Letter 50-07, Attachment 2 2

7 List every town and city in Texas where the individual has lived since the age of 14. Provide the date when the individual began living in or frequenting your home. Provide the race and ethnicity of the individual. Provide all other names (married, maiden, etc.,) that the individual may have used. Mailing Instructions: Mail this form to your DFPS Local Licensing Office. Texas Workforce Center staff can provide you a list of addresses for DFPS Local Child Care Licensing Offices. Child Care Fee Schedule, Form 2988 Your Information: Provide your name as the Operation Name. This must be the same name as appears on the Listing Request, Form Write N/A for the Operation Number. This number will be provided to you upon approval of your listing permit by DFPS. Provide the street address, mailing address, county, and telephone number that you provided on the Listing Request, Form Provide the DFPS District i.e., the areas, Central Texas, North Texas, etc., specified on the list of addresses for DFPS Local Child Care Licensing Offices. Texas Workforce Center staff can provide this list to you. Type of Fee Being Paid: Check the Listing Request Fee box. Write $20 in the space provided. Total Amount of Fees Paid: $20. Note: This $20 fee includes the background check and you are not required to pay any additional fees for multiple background checks. Mailing Instructions: Do not send cash. Personal checks are accepted. Make checks payable to the Texas Department of Family and Protective Services. Attach the $20 fee to your completed Child Care Fee Schedule, Form 2988, and mail it to the address below. This is the only form that you mail to this address. All other forms must be mailed to your DFPS Local Child Care Licensing Office. Texas Department of Family and Protective Services Accounting Division E-672 P.O. Box Austin, Texas You are encouraged to keep a copy of the completed forms and payment information for your records. WD Letter 50-07, Attachment 2 3

8 Texas Dept of Family Form 2986 and Protective Services LISTING REQUEST July 2007 Texas law gives you the right to know what information is collected about you by means of a form you submit to a state government agency. You can receive and review this information, and request that incorrect information about you be corrected by contacting your licensing representative. Name (last, first, middle) Social Security No.* Tx. Driver s Lic. No.* Date of Birth Other names I have used or have been known by (maiden, married, etc.) / / Street Address (if rural, attach directions) City County Zip Mailing Address (if different) -- Street or P.O. Box City County Zip Telephone No. (include A/C) *Indicate if you do not have a Social Security number or a Texas driver s license or if your driver s license is out-of-state 1. The following people (spouse, children, friends, etc.) live in my home with me or are regularly or frequently present while children are in my care: NAME (last, first, middle) AGE DATE OF BIRTH SOCIAL SECURITY NO.* TX. DRIVER S LICENSE NO.* RELATIONSHIP *Indicate if none. 2. Will any other people assist you in caring for children? YES NO If Yes, provide the following information on the people who will assist you (include their names on Form 2971): Name (last, first, middle) Social Security No.* Tx. Driver s Lic. No.* Date of Birth Address - Street City Zip Telephone No. (A/C) Name (last, first, middle) Social Security No.* Tx. Driver s Lic. No.* Date of Birth Address - Street City Zip Telephone No. (A/C) 3. A. Are you requesting to be listed in order to receive a federal child-care subsidy? YES NO B. Are you now caring for children in your home who are not related to you? YES NO C. How many children are you caring for or do you intend to care for? (related), (unrelated). 1 of 3

9 Texas Dept of Family Form 2986 and Protective Services July Has any agency of the State of Texas ever licensed, registered, or listed you to care for children? YES NO If yes, when were you licensed/registered/listed? Address (Street, City, Zip) County(ies) If licensed/registered or listed under another name(s), list name(s): 5. TDFPS posts information about your operation and its compliance history on our public web site at If your address, phone or other information changes, please inform your local licensing office. INFORMATION FOR TDFPS WEB SITE Phone #: ( ) Fax #: ( ) Address: Web Page Address: Pager # ( ) Cell Phone.# ( ) OPERATION: (Please check all that apply) Hours of operation: Begin time End time Days of operation: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Months of Operation: Year round or January February March April May June July August September October November December Ages Served: Infants (birth -17 months) Toddlers (18 months 2 years) Pre-kindergartnen (3 years 4 years) School-age (5 yrs and older) SERVICES OFFERRED: (Please check all that apply): Child and Adult Care Food Program Subsidized Child Care After-School Care Part-Time Care Get Well Care Special Skills Classes (will enroll children for only part of the day and/or week) (for ill or recovering children) Drop-In Care (Alternate Care) Special Needs Care Program Water Activities Accredited by National Organization Wheelchair Accessible Pool on Premises Employer-based Child Care (open only to employees) Language (primary language spoken in the facility) Please enter DIRECTIONS TO LOCATION: (Please give clear concise directions) Educational Program for Pre- Kindergarten Educational Program for Kindergarten and Above Transportation Field Trips If you wish to provide additional information, please contact your licensing representative. NOTE: Persons requesting listing have the option of attending a child-care orientation in health, safety, and sanitation related to preventing risk to children. Contact your local licensing office for more information. Information contained in this Request may be required by law to be released to the public. 2 of 3

10 Texas Dept of Family Form 2986 and Protective Services July 2007 FOR DFPS USE ONLY Criminal History Central Registry Date Received Date Entered Date Completed Date Received Date Entered Date Completed Date Request Rec d Date Accepted Date Fee Verified Amount Paid Method of Verification By: I request to list with the Texas Department of Family and Protective Services to provide child care. I agree to comply with the Department s rules and all provisions of Chapter 42 of the Human Resources Code (the child care licensing law) that apply to listed family homes. I understand I am to notify the Texas Department of Family and Protective Services if I move or when I am no longer caring for children. I also certify that the information I have given contains no willful misrepresentation or falsification and that it is true and complete to the best of my knowledge and belief. I understand that any willful misrepresentation is cause for immediate denial or revocation of my listing. I authorize the Texas Department of Family and Protective Services to contact people listed on this form. I authorize the Texas Department of Public Safety to release my criminal history record information to the Texas Department of Family and Protective Services. Signature Date 3 of 3

11 Texas Dept of Family REQUEST FOR CRIMINAL HISTORY Form 2971 and Protective Services AND CENTRAL REGISTRY CHECK Texas law gives you the right to know what information is collected about you by means of a form you submit to a state government agency. You can receive and review this information, and request that incorrect information about you be corrected by contacting your licensing representative. Operation Name Operation Number Telephone No. (A/C) October 2006 Pg. 1 of 2 Operation Address (Street, City, ZIP) Operation Mailing Address (City & Zip) County Chapter 42 of the Human Resources Code requires the director, owner or operator of a child care facility or family home to provide identifying information on the director, owner and/or operator, each employee and each person 14 years of age or older who will regularly or frequently be staying or working at the facility or home while the children are in care (other than a child in care at the facility or home). This information will be used to check for any criminal history that is a violation of minimum standards and the Department s central registry of abuse and neglect. It may be necessary for you to obtain additional information if the person does not live in Texas or may have a criminal history in another state. The criminal history and central registry checks are not intended to delay hiring new staff. You will be notified of the results of the check. I verified (by looking at the person s social security card and/or driver license) that the information on this form contains no willful misrepresentation and that the information given is true and complete to the best of my knowledge. I understand that the Department may contact others and, at any time, seek proof of any information contained here. I understand that any willful misrepresentation or failure to provide identifying information within the stated time limit is a cause for denial of the application or revocation of my license, registration or listing. Signature of Director, Owner, or Operator Date Complete the following for each person requiring a Criminal History/Central Registry Check; verify that the information is accurate by checking the person s social security card and/or driver license; and return all required background check request forms to your local licensing office. All names used currently or in the past by the person must be entered. Without these names you may get cleared results when there is actually a match. If a new person is being hired you must submit the request TO YOUR LOCAL LICENSING OFFICE WITHIN TWO DAYS after the person is hired or is present in the operation. Requests for background checks may be submitted by mail or through the TDFPS Internet at the following address: If you are submitting your request through the Internet please DO NOT submit this form to your licensing office. If you are not submitting your request through the Internet the background check request form must be submitted to YOUR LOCAL LICENSING OFFICE. Additional copies of this forms may be obtained on the DFPS web site. For each person listed on this form or submitted through the Internet, a $2 fee must be paid. A Form 2988-A, Child Care Fee Schedule, along with the fee(s), must be submitted to: TDFPS, Accounting Division E-672, P.O. Box , Austin, TX Failure to submit fee payments can result in adverse action including suspension or revocation. Initial 24 Month Check FBI Check Required Social Security Number ID Type - Drivers License or ID Number -State First Name Middle Name Last Name Street Address City State Zip County Telephone No. (A/C) Date of Birth Gender M You must list all other cities in Texas where there has been residency. If you lived outside of Texas in the previous 5 years you must also list previous address(es) outside of Texas, including the county: Relationship of person to requestor Adoptive Parent Staff Other Staff Other Caregiver Foster parent Licensed Administrator F Director Household Member Volunteer Date Hired /Used by the Operation/Agency Ethnicity (must accompany race) Race White Asian/Pacific Islander Hispanic Other Black American Indian/Alaskan Native Other names used (married, maiden, etc.) First Name Middle Name Last Name Worker Name--Last, first Mail Code District Operation No. Operation Type DFPS Use Only Date Received Date Criminal History Entered Date Central Registry Checked Date FBI Card Submitted

12 Dept of Family REQUEST FOR CRIMINAL HISTORY Form 2971 and Protective Services AND CENTRAL REGISTRY CHECK October 2006 Pg. 2 of 2 Complete the following for each person requiring a Criminal History/Central Registry Check and return this form to the Licensing Office. Additional forms may be obtained from the Licensing office. Initial 24 Month Check FBI Check Required Social Security Number First Name Middle Name Last Name ID Type - Drivers License or ID Number - State Street Address City State Zip County Telephone No. (A/C) Date of Birth Gender M You must list all other cities in Texas where there has been residency. If you lived outside of Texas in the previous 5 years you must also list previous address(es) outside of Texas, including the county: Relationship of person to requestor Adoptive Parent Staff Other Staff Other Caregiver Foster parent Licensed Administrator F Director Household Member Volunteer Date Hired /Used by the Operation/Agency Ethnicity (must accompany race) Race White Asian/Pacific Islander Hispanic Other Black American Indian/Alaskan Native Other names used (married, maiden, etc.) First Name Middle Name Last Name Initial 24 Month Check FBI Check Required Social Security Number ID Type - Drivers License or ID Number - State First Name Middle Name Last Name Street Address City State Zip County Telephone No. (A/C) Date of Birth Gender M You must list all other cities in Texas where there has been residency. If you lived outside of Texas in the previous 5 years you must also list previous address(es) outside of Texas, including the county: Relationship of person to requestor Adoptive Parent Staff Other Staff Other Caregiver Foster parent Licensed Administrator F Director Household Member Volunteer Date Hired /Used by the Operation/Agency Ethnicity (must accompany race) Race White Asian/Pacific Islander Hispanic Other Black American Indian/Alaskan Native Other names used (married, maiden, etc.) First Name Middle Name Last Name

13 Texas Dept of Family and Protective Services Please check if this is a change of address. Operation Name (if Registered Child Care or Listed Family Home, enter your name only): CHILD CARE FEE SCHEDULE Form 2988 January 2007 Operation No. (on your permit): Operation Street Address: City: County: Zip TYPE OF FEE BEING PAID NOTE: This form must be attached to all child-care fee payments submitted to DFPS accounting division. Payments received without this form may delay proper processing of your payment. If your payment is not properly processed it will be shown as unpaid and can result in adverse action taken against your operation including suspension or revocation. RETURN ONLY THIS FORM WITH YOUR LICENSING FEE PAYMENT IN THE RETURN ENVELOPE ADDRESSED TO: DFPS Accounting Division E-672, P.O. Box , Austin, Texas PAC-610 OBJ All other forms should be mailed directly to your local Licensing Office District Telephone Number - - AMOUNT FOR LISTED FAMILY HOMES ONLY: Listed Family Home Fee: A $20 fee paid when the listing is requested and at the anniversary date of issuance. The background check fees are included in this. Listing Request Fee Annual Listing Renewal Fee $ FOR REGISTERED CHILD-CARE HOMES ONLY: Registered Child-Care Home Fee: A $35 fee paid when the registration is requested and at the anniversary date of issuance. Registration Request Fee Annual Registration Renewal Fee $ LICENSED OPERATIONS: Please refer to the description below for the types of fees: Operation Type (check one) Fee Type (check all that apply) Licensed Care Center Licensed Care Home Child-Placing Agency Foster Family Home Foster Group Home Residential Treatment Center General Residential Operation Maternity Homes Application Initial Initial Renewal Non-expiring license fee Annual Renewal Amendment Supplemental CAPACITY. Number of children for which you are or will be licensed: x $1 (This applies to those licensed operations that are obtaining their non-expiring license or paying annual renewal fees: it does not apply to centers that are applying/paying for application and initial license.) Maternity homes: Number of children for which you are or will be Licensed: x $2 Is this a change in the number of children from your previous Licensing? Yes No APPLIES TO ALL OPERATIONS EXCEPT LISTED FAMILY HOMES: Background Check Fee Number of Persons being checked: x $2 Amount of Fee paid: plus additional fee, if applicable Total Capacity Fee: $ $ $ Total amount of Background Check Fees: $ TOTAL AMOUNT OF FEES PAID: $ Check if you would like to receive the Texas Child Care quarterly journal at no cost. This information is needed to determine postage rates. FEE DEFINITIONS Application Fee: A nonrefundable fee of $35 for an initial application for a license to operate a child care operation, child-placing agency or maternity home. This fee is paid when the application is submitted. Initial License Fee: A $35 fee for a child care operation (other than a child-placing agency and maternity home). A $50 fee for a child-placing agency and maternity home. This fee is paid when the application is submitted. Initial Renewal: $35.00 fee for a child care operation. A $50 fee for a child-placing agency and maternity home. The fee is paid when the initial license is renewed. Non-expiring licensing fee and annual fee: A $35 fee for a child care operation plus $1 for each child the operation is licensed to serve (other than a childplacing agency and maternity home); a $100 fee for a child-placing agency; a $50 fee for maternity home plus $2 for each child the home is licensed to serve. This fee is paid before the non-expiring license is issued and at the anniversary date of issuance. Amendment License Fee (for increase in licensed capacity ONLY): A $1 fee for each child that the current licensed capacity is increased (other than maternity homes; for maternity homes an amendment fee of $2 is required for each client that the current licensed capacity is increased.) Registered Child-Care Home Fee: A $35 fee paid when the registration is requested and at the anniversary date of issuance. Listed Family Home Fee: A $20 fee paid when the listing is requested and at the anniversary date of issuance. This includes the Background check fees. Background Check Fee: $2.00 per person submitted. (The Background Check fee(s) must be submitted with this form to the address below. The Form 2971, Request for Criminal History and Central Registry Check, must be submitted separately to your local licensing office.) Exemption: Certified or state-run operations are exempt from fees. Independent Licensed Foster Family and Foster Group Homes and Non-Profit 24-hour Care Operations that charge no fees for their services or Non-Profit Operations that provide residential care for children in the managing conservatorship of DFPS during the 12-month period immediately preceding the annual anniversary of the permit must pay application fees but are exempt from paying all other fees. Make Payable To: Department of Family and Protective Services KEEP YOUR RECEIPT STUB OR CANCELED CHECK NO RECEIPT WILL BE SENT - DO NOT SEND CASH

INTERN APPLICATION. Thank You for applying for internship at St. PJ's!

INTERN APPLICATION. Thank You for applying for internship at St. PJ's! INTERN APPLICATION Please complete the application and return to the hiring Supervisor. Copies of your Driver License or State ID, Social Security Card and Cover letter and Resume are also needed. The

More information

EMPLOYMENT APPLICATION

EMPLOYMENT APPLICATION EMPLOYMENT APPLICATION Thank you for your interest in the YMCA of Metropolitan Detroit! The YMCA of Metropolitan Detroit is an equal opportunity employer and does not discriminate in recruitment, hiring

More information

RENTAL HOUSING APPLICATION

RENTAL HOUSING APPLICATION OFFICE USE ONLY: Property: Date/Time: 901 30th Street Paso Robles, CA 93446 Phone: (805) 238-4015 Fax (805) 238-4036 Bdrm size: Waitlist No: Hhld Size: AMI: % Applicant RENTAL HOUSING APPLICATION M / F

More information

APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT APPLICATION FOR EMPLOYMENT An Equal Opportunity/Affirmative Action Employer, the City of Dallas does not discriminate in employment with regard to race, color, sex, marital status, age, religion, national

More information

Thank you for requesting an application for an apartment. Enclosed, please find an application package.

Thank you for requesting an application for an apartment. Enclosed, please find an application package. Dear Applicant, Thank you for requesting an application for an apartment. Enclosed, please find an application package. Please read the application carefully, complete every section, and date where indicated.

More information

CHAPTER 168. CHILD CARE GENERAL PROVISIONS

CHAPTER 168. CHILD CARE GENERAL PROVISIONS Ch. 168 CHILD CARE 55 CHAPTER 168. CHILD CARE GENERAL PROVISIONS Sec. 168.1. Policy on payment of child care. 168.2. Definitions. 168.3. Authority to administer subsidized child care. ELIGIBILITY REQUIREMENTS

More information

Application Information for Children s Health Insurance Program (CHIP), Children s Medicaid, and CHIP perinatal coverage

Application Information for Children s Health Insurance Program (CHIP), Children s Medicaid, and CHIP perinatal coverage Application Information for Children s Health Insurance Program (CHIP), Children s Medicaid, and CHIP perinatal coverage CHIP CHIP covers children from birth through age 18 who do not qualify for Medicaid

More information

Child Care Assistance. Regulated Child Care. Provider Manual. Provider Information Line: 214.905.3579. Billing and Attendance Assistance: 214.905.

Child Care Assistance. Regulated Child Care. Provider Manual. Provider Information Line: 214.905.3579. Billing and Attendance Assistance: 214.905. Child Care Assistance Regulated Child Care Provider Manual Provider Information Line: 214.905.3579 Billing and Attendance Assistance: 214.905.3570 Payment Information Line: 214.905.2474 8585 N. Stemmons

More information

PLEASE SUBMIT ONLY ONE (1) APPLICATION PER HOUSEHOLD EVEN IF YOU ARE INTERESTED IN MORE THAN ONE (1) PROPERTY. THANK YOU.

PLEASE SUBMIT ONLY ONE (1) APPLICATION PER HOUSEHOLD EVEN IF YOU ARE INTERESTED IN MORE THAN ONE (1) PROPERTY. THANK YOU. Dear Applicant: Thank you for your recent inquiry of occupancy at a Carabetta Management Company apartment community. Due to the nature of Federal Assistance provided for these properties, we are required

More information

Texas Department of Insurance Individual Insurance License Application

Texas Department of Insurance Individual Insurance License Application Texas Department of Insurance Individual Insurance License Application This application is only for applicants who must take or have taken a Prometric examination and applicants for a temporary license.

More information

Children s Advocacy Center for Denton County Community Outreach Coordinator Job Position Duties & Responsibilities Effective 1/1/14

Children s Advocacy Center for Denton County Community Outreach Coordinator Job Position Duties & Responsibilities Effective 1/1/14 Children s Advocacy Center for Denton County Community Outreach Coordinator Job Position Duties & Responsibilities Effective 1/1/14 Reports To: Position Overview: Development Director CACDC is seeking

More information

Child Care Assistance. Regulated Child Care. Provider Manual

Child Care Assistance. Regulated Child Care. Provider Manual Child Care Assistance Regulated Child Care Provider Manual Provider Information Line: 214.905.3579 Email: providerinfo@ccgroup.org Fax: 214.905.2471 Billing and Attendance Assistance: 214.905.3570 Email:

More information

Instructions to fill out this Application

Instructions to fill out this Application Application Information for Children s Health Insurance Program (CHIP), Children s Medicaid, and CHIP perinatal coverage CHIP CHIP offers health care for children, from birth to age 18, whose families

More information

Direct Deposit Enrollment Form CHECK ONE I do not want to enroll in direct Deposit at this time. I would like to be paid by check (Skip this page and

Direct Deposit Enrollment Form CHECK ONE I do not want to enroll in direct Deposit at this time. I would like to be paid by check (Skip this page and Military Fee Assistance Programs CHILD CARE PROVIDER ELIGIBILITY APPLICATION You may also apply online at fap.americasteamforchildcare.org Provider/Program Doing Business As (DBA) Name: Provider Services

More information

Ohiopyle Prints, Inc.

Ohiopyle Prints, Inc. Ohiopyle Prints, Inc. 410 Dinner Bell Road Ohiopyle, PA 15470 724-329-4652 2016 STUDENT SUMMER WORK PROGRAM Starting Pay $7.25 / hr $50 Attendance Bonus Plan Must be 16 years or older and have a valid

More information

STAGE COACH RESIDENCES 70 STAGE COACH ROAD, CENTERVILLE

STAGE COACH RESIDENCES 70 STAGE COACH ROAD, CENTERVILLE STAGE COACH RESIDENCES 70 STAGE COACH ROAD, CENTERVILLE Thank you for your interest in the Stage Coach Residences (12) apartments that are available for rental to low and moderate income households. Six

More information

Again, thank you for your support we hope to see you around the Center soon! Anne West Volunteer Coordinator. Dear Prospective Volunteer,

Again, thank you for your support we hope to see you around the Center soon! Anne West Volunteer Coordinator. Dear Prospective Volunteer, Dear Prospective Volunteer, Thank you for your interest in volunteering with the Center for Child Protection. Volunteers provide the vital support needed for the Center s successful operation and we offer

More information

License Application to Make Retail Sales of Cigarette and Other Tobacco Products

License Application to Make Retail Sales of Cigarette and Other Tobacco Products License Application to Make Retail Sales of Cigarette and Other Tobacco Products CITY OF SHAKOPEE 129 Holmes Street South Shakopee, MN 55379 952-233-9300 Licensee s legal name Daytime Phone Business trade

More information

Resource Family Application Registration / Update Form (CY 131) Instructions

Resource Family Application Registration / Update Form (CY 131) Instructions Submit to When to use Used By Comments Resource Family Application Registration / Update Form (CY 131) Instructions Pennsylvania Adoption Exchange, P.O. Box 4469, Harrisburg PA 17111-0469, fax to 1-717-236-8510.

More information

APPLICATION FOR A PROVISIONAL (SPECIAL EDUCATION) VIRGINIA LICENSE

APPLICATION FOR A PROVISIONAL (SPECIAL EDUCATION) VIRGINIA LICENSE APPLICATION FOR A PROVISIONAL (SPECIAL EDUCATION) VIRGINIA LICENSE PLEASE NOTE: THIS APPLICATION MUST BE SUBMITTED BY A VIRGINIA PUBLIC SCHOOL DIVISION OR VIRGINIA ACCREDITED NONPUBLIC SCHOOL. Thank you

More information

APPLICATION FOR A VIRGINIA PROVISIONAL (SPECIAL EDUCATION) LICENSE

APPLICATION FOR A VIRGINIA PROVISIONAL (SPECIAL EDUCATION) LICENSE APPLICATION FOR A VIRGINIA PROVISIONAL (SPECIAL EDUCATION) LICENSE Please refer to the Licensure Regulations for School Personnel on the s Web site to review requirements for this license (http://www.doe.virginia.gov/teaching/licensure/index.shtml).

More information

Application for Subsidized Child Care

Application for Subsidized Child Care COMMONWEALTH OF PENNSYLVANIA Application for Subsidized Child Care This application may be used by families who want help in paying their child care costs. The Child Care Information Services (CCIS) agency

More information

Nursing Student Loan Forgiveness Program Application Package

Nursing Student Loan Forgiveness Program Application Package Nursing Student Loan Forgiveness Program Application Package Nursing Student Loan Forgiveness Program Information, Initial Application, Employment Verification and Loan Principal Certification Florida

More information

HOMESTUDY PROCEDURES

HOMESTUDY PROCEDURES HOMESTUDY PROCEDURES Inquiry Process Adoption by Gentle Care shall respond to adoption inquiries within 48 business hours and shall provide the following information: 1. A link to the JFS form 01675 Ohio

More information

APPLICATION PROCESS. Page 1 of 5

APPLICATION PROCESS. Page 1 of 5 APPLICATION PROCESS 1. APPLICANT: A complete application is required for each adult 18 years of age and older. All adult applicants must completely and accurately fill out a separate application. Applications

More information

New York Lifeline Application

New York Lifeline Application New York Lifeline is a government program that provides a monthly discount on home or mobile telephone services. Only ONE Lifeline discount is allowed per household. Members of a household are not permitted

More information

All eligible applicants go on the waiting list and when funding becomes available, families are outreached by wait/date order.

All eligible applicants go on the waiting list and when funding becomes available, families are outreached by wait/date order. Dear Parent, Thank you for your interest in the Child Care Assistance program. Attached you will find the application form for you to complete. Outlined below are the basic eligibility guidelines for the

More information

TAX DEFERRAL INFORMATION AND INSTRUCTION SHEET

TAX DEFERRAL INFORMATION AND INSTRUCTION SHEET CECIL COUNTY, MARYLAND OFFICE OF FINANCE 200 CHESAPEAKE BLVD, STE. 1100 ELKTON, MARYLAND 21921 TAX DEFERRAL INFORMATION AND INSTRUCTION SHEET The Annotated Code of Maryland, Tax-Property Article 10-204

More information

New Hire Booklet. Employee Name. Company Code 0104-0801. 2001 ADP TotalSource Services, Inc.

New Hire Booklet. Employee Name. Company Code 0104-0801. 2001 ADP TotalSource Services, Inc. New Hire Booklet Employee Name Company Code 2001 ADP TotalSource Services, Inc. 0104-0801 Welcome to ADP TotalSource The Basic Employment Policies included in this Booklet will explain your relationship

More information

Application & Renewal Form

Application & Renewal Form Section A: I want health insurance for: (Check ( ) the category or categories that match your situation.) Myself, my spouse (or other parent of my children) and our children under age 19 who live with

More information

PRACTITIONER REGISTRY APPLICATION

PRACTITIONER REGISTRY APPLICATION Pract Application Rev 06/23/2014 Page 1 PRACTITIONER REGISTRY APPLICATION The Registry verifies trainers, registers training, and tracks the professional development of both practitioners and trainers.

More information

APPLICATION FOR A VIRGINIA LICENSE

APPLICATION FOR A VIRGINIA LICENSE Virginia Department of Education P. O. Box 2120 Richmond, VA 23218-2120 APPLICATION FOR A VIRGINIA LICENSE (Application for a teaching license, collegiate professional license, postgraduate professional

More information

T.E.A.C.H. Early Childhood WISCONSIN Scholarship Application

T.E.A.C.H. Early Childhood WISCONSIN Scholarship Application T.E.A.C.H. Early Childhood WISCONSIN Scholarship Application Instructions 1 Fill out application completely and submit all items listed below. If information is missing or not all questions on the application

More information

Nursing Assistant Program Application

Nursing Assistant Program Application Page 1 of 5 Nursing Assistant Program Application Return completed packet along with $20.00 check/money order payable to WCTC: Attn: Nursing Assistant Program, Office H101 800 Main St Pewaukee, WI 53072

More information

Military Fee Assistance Payment Policies and Procedures

Military Fee Assistance Payment Policies and Procedures Military Fee Assistance Payment Policies and Procedures Please read carefully. These policies will assist you in completing and submitting your monthly attendance records. Our staff is available to answer

More information

Pharmacy Technician. Program. Weatherford College in Partnership with Condensed Curriculum International (CCI) KEEP THIS SCHEDULE FOR YOUR RECORDS.

Pharmacy Technician. Program. Weatherford College in Partnership with Condensed Curriculum International (CCI) KEEP THIS SCHEDULE FOR YOUR RECORDS. Pharmacy Technician Weatherford College in Partnership with Condensed Curriculum International (CCI) Program Summary: As a Pharmacy Technician you will help the pharmacist package or mix prescriptions,

More information

IMPORTANT! PLEASE READ THIS ENTIRE NOTICE

IMPORTANT! PLEASE READ THIS ENTIRE NOTICE IMPORTANT! PLEASE READ THIS ENTIRE NOTICE Completed Applications May Be Returned by email to: apply@ccmanagers.com by Fax to 212-348-3670 or by Mail. Do NOT return page 1 & 2 with your application YOU

More information

Relative Child Care Provider. Handbook. 1420 W. Mockingbird, Suite 300 Dallas, TX 75247 tel\214.630.5949 fax\214.688.4436 web\www.childcaregroup.

Relative Child Care Provider. Handbook. 1420 W. Mockingbird, Suite 300 Dallas, TX 75247 tel\214.630.5949 fax\214.688.4436 web\www.childcaregroup. Relative Child Care Provider Handbook 1420 W. Mockingbird, Suite 300 Dallas, TX 75247 tel\214.630.5949 fax\214.688.4436 web\www.childcaregroup.org FOREWORD The ChildCareGroup Child Care Assistance program

More information

Healthy Kids Annual Renewal Application

Healthy Kids Annual Renewal Application Healthy Kids Annual Renewal Application Application Due By: It is time to renew your Healthy Kids health care coverage. If you would like it in another language, please call (415) 777-9992. It is time

More information

FLORIDA. Parent and School Handbook. Florida Tax Credit Scholarship Program

FLORIDA. Parent and School Handbook. Florida Tax Credit Scholarship Program FLORIDA Parent and School Handbook Florida Tax Credit Scholarship Program AAA Scholarship Foundation Florida Phone & Fax #: 888-707-2465 ~ mail: Florida@aaascholarships.org Corporate Office Mailing Address:

More information

LICENSING AT A LOWER LEVEL

LICENSING AT A LOWER LEVEL EMS-APP-500 (11/2014) Michigan Department of Community Health Lansing, Michigan 48909 Website: www.michigan.gov/ems Authority: P.A. 368 of 1978, as amended This form is for information only. MICHIGAN COURSE

More information

APPLICATION FOR A VIRGINIA LICENSE

APPLICATION FOR A VIRGINIA LICENSE Virginia Department of Education P. O. Box 2120 Richmond, Virginia 23218-2120 APPLICATION FOR A VIRGINIA LICENSE (Application for a teaching license, collegiate professional license, postgraduate professional

More information

GOODWILL EMPOWERMENT SCHOLARSHIP GUIDELINES

GOODWILL EMPOWERMENT SCHOLARSHIP GUIDELINES GOODWILL INDUSTRIES OF FORT WORTH GOODWILL EMPOWERMENT SCHOLARSHIP GUIDELINES The Goodwill Industries Empowerment Scholarship will award a total of four individuals up to $1,300 per academic year ($650

More information

Child Care Assistance Application Checklist

Child Care Assistance Application Checklist State of Alaska Department of Health and Social Services Division of Public Assistance Child Care Program Office http://www.hss.state.ak.us/dpa/programs/ccare/ Child Care Assistance Application Checklist

More information

Kane County Foreclosure Redevelopment Program. Home Buyer Application

Kane County Foreclosure Redevelopment Program. Home Buyer Application Kane County Foreclosure Redevelopment Program Home Buyer Application To apply to purchase a home that was redeveloped under the Kane County Foreclosure Redevelopment Program Please follow these three easy

More information

Child Care WAGE$ IOWA Compensation Project

Child Care WAGE$ IOWA Compensation Project Child Care WAGE$ IOWA Compensation Project Child Care WAGE$ IOWA is a licensed program of Child Care Services Association APPLICATION Contact Information: Name Preferred Name (first) (MI) (last) Address

More information

EMPLOYMENT APPLICATION {PLEASE Print Clearly}

EMPLOYMENT APPLICATION {PLEASE Print Clearly} Date Received: Next Step: EMPLOYMENT APPLICATION {PLEASE Print Clearly} Date: Position applied for: Personal Information Legal Name: First Last Middle Initial Address: Street City State Zip code How long

More information

The child must be younger than 18 years old and meet one of the following criteria when the adoptive placement agreement is signed:

The child must be younger than 18 years old and meet one of the following criteria when the adoptive placement agreement is signed: DFPS Adoption Assistance Description: Definition of Special Needs: The child must be younger than 18 years old and meet one of the following criteria when the adoptive placement agreement is signed: 1.

More information

If there are any questions, please feel free to contact us directly. We will do our best to make your home study experience as positive as possible.

If there are any questions, please feel free to contact us directly. We will do our best to make your home study experience as positive as possible. Dear Home Study Applicant, Thank you for considering Adoption Makes Family as the agency to conduct your home study. We consider it a privilege to help families through the adoption process. Adoption is

More information

Incumbent Worker Training Program Application

Incumbent Worker Training Program Application Incumbent Worker Training Program Application Release Date: September 2007 Application Due Date and Time: Open application process (dependent on available funding) The mission of the Workforce Solutions

More information

DIVISION OF MEDICAL QUALITY ASSURANCE BOARD OF PHARMACY 4052 BALD CYPRESS WAY, BIN #C-04 TALLAHASSEE, FLORIDA 32399-3254 (850) 245-4292

DIVISION OF MEDICAL QUALITY ASSURANCE BOARD OF PHARMACY 4052 BALD CYPRESS WAY, BIN #C-04 TALLAHASSEE, FLORIDA 32399-3254 (850) 245-4292 DIVISION OF MEDICAL QUALITY ASSURANCE BOARD OF PHARMACY 4052 BALD CYPRESS WAY, BIN #C-04 TALLAHASSEE, FLORIDA 32399-3254 (850) 245-4292 CONSULTANT PHARMACIST APPLICATION AND INFORMATION July 2012 DH-MQA

More information

HHSC is accepting applications for representatives to serve on the Texas Nonprofit Council.

HHSC is accepting applications for representatives to serve on the Texas Nonprofit Council. HHSC is accepting applications for representatives to serve on the Texas Nonprofit Council. Background The Texas Nonprofit Council was established by S.B 993 during the 83 rd Legislation Session in 2013.

More information

GOVERNMENT OF THE DISTRICT OF COLUMBIA Department of Health Health Professional Licensing Administration. Board of Dietetics and Nutrition

GOVERNMENT OF THE DISTRICT OF COLUMBIA Department of Health Health Professional Licensing Administration. Board of Dietetics and Nutrition GOVERNMENT OF THE DISTRICT OF COLUMBIA Department of Health Health Professional Licensing Administration Board of Dietetics and Nutrition APPLICATION INSTRUCTIONS AND FORMS FOR A LICENSE TO PRACTICE NUTRITION

More information

T.E.A.C.H. Early Childhood Alabama Associate Degree Scholarship Application for Family Child Care Home Providers

T.E.A.C.H. Early Childhood Alabama Associate Degree Scholarship Application for Family Child Care Home Providers GENERAL INFORMATION: Social Security Number: - - Date: Name: Address: Apt #: City: State: Zip: County: Phone: Home: ( ) Cell: ( ) Work: ( ) Email Address: Date of Birth (mm/dd/yyyy): / / Gender: Female

More information

APPLICATION FOR A PROVISIONAL (SPECIAL EDUCATION) VIRGINIA LICENSE

APPLICATION FOR A PROVISIONAL (SPECIAL EDUCATION) VIRGINIA LICENSE APPLICATION FOR A PROVISIONAL (SPECIAL EDUCATION) VIRGINIA LICENSE PLEASE NOTE: THIS APPLICATION MUST BE SUBMITTED BY A VIRGINIA PUBLIC SCHOOL OR ACCREDITED NONPUBLIC SCHOOL. Thank you for your interest

More information

CIVIL SERVICE COMMISSION CITY OF TYLER, TEXAS. Announces an Examination for FIRE RECRUIT

CIVIL SERVICE COMMISSION CITY OF TYLER, TEXAS. Announces an Examination for FIRE RECRUIT CIVIL SERVICE COMMISSION CITY OF TYLER, TEXAS Announces an Examination for FIRE RECRUIT ANNOUNCENIENT OPENS: TUESDAY, APRIL 2, 2013 AT 9:30 A.M. APPLICATION DEADLINE: FRIDAY, MAY 3, 2013 AT 5:00 P.M. TEST

More information

The Dependent Care Flexible Spending Account may be used to pay dependent care expenses that are necessary for you and your spouse to work.

The Dependent Care Flexible Spending Account may be used to pay dependent care expenses that are necessary for you and your spouse to work. DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT The Dependent Care Flexible Spending Account may be used to pay dependent care expenses that are necessary for you and your spouse to work. Eligibility Employee

More information

After reviewing all of your application materials, we will contact you to discuss your eligibility to move forward in the selection process.

After reviewing all of your application materials, we will contact you to discuss your eligibility to move forward in the selection process. Dear Potential Student: Thank you for your inquiry about the Gap Tuition Assistance program at Kirkwood Community College. The application materials are enclosed for you to start the process for consideration

More information

CITY OF VICTORVILLE. APPLICATION Administered by Neighborhood Partnership Housing Services, Inc.

CITY OF VICTORVILLE. APPLICATION Administered by Neighborhood Partnership Housing Services, Inc. CITY OF VICTORVILLE OWNER OCCUPIED HOME REPAIR LOAN APPLICATION Administered by Neighborhood Partnership Housing Services, Inc. Submit completed application and all requested information to: NPHS, Inc.

More information

Certified Registered Nurse Anesthetist General Instructions for Licensure Application

Certified Registered Nurse Anesthetist General Instructions for Licensure Application 4305 S. LOUISE AVENUE SUITE 201 SIOUX FALLS, SD 57106-3115 (605) 362-2760 Fax: 362-2768 doh.sd.gov/boards/nursing General Instructions for Licensure Application Please follow instructions carefully to

More information

DIOCESE OF CHARLESTON BACKGROUND SCREENING BASIC DATA FORM Forms must be completed in their entirety to be processed.

DIOCESE OF CHARLESTON BACKGROUND SCREENING BASIC DATA FORM Forms must be completed in their entirety to be processed. DIOCESE OF CHARLESTON BACKGROUND SCREENING BASIC DATA FORM Forms must be completed in their entirety to be processed. Diocesan Parish/School/Office Use Only: Parish/School/Office Location: Submitted by:

More information

Provider Information Change Form I. PERSONAL INFORMATION

Provider Information Change Form I. PERSONAL INFORMATION Internal #: For Internal Use Only (Individual Application) Reason: New Provider Provider Information Change Form I. PERSONAL INFORMATION Name:.. First Middle Last Suffix Degree (MD,RN, etc.) Gender: M

More information

T.E.A.C.H. Early Childhood MISSISSIPPI Associate Degree Scholarship Application for Child Care Center Teachers

T.E.A.C.H. Early Childhood MISSISSIPPI Associate Degree Scholarship Application for Child Care Center Teachers GENERAL INFORMATION: Social Security Number: - - Date: Name: Address: Apt #: City: State: Zip: County: Phone: Home: ( ) Cell: ( ) Work: ( ) Email Address: Date of Birth (mm/dd/yyyy): / / Gender: Female

More information

New Group Application East Region New business effective Jan. 1, 2011

New Group Application East Region New business effective Jan. 1, 2011 New Group Application East Region New business effective Jan. 1, 2011 2-50 Eligible employees PriorityHMO SM PriorityPOS SM PriorityPPO SM Revised 10/10 Life just got a little easier. This comprehensive

More information

30 Day Limited Permits for Professional Engineers and Land Surveyors

30 Day Limited Permits for Professional Engineers and Land Surveyors THE STATE EDUCATION DEPARTMENT / THE UNIVERSITY OF THE STATE OF NEW YORK / ALBANY, NY 12234 Office of the Professions, State Board for Engineering and Land Surveying PHONE: 518-474-3817 ext. 140 FAX: 518-473-6282

More information

8. Permanent Address (Street or P.O. Box) City State Zip Code. 9. E-mail Address 10. Home Phone Number 11. Work Phone Number 12.

8. Permanent Address (Street or P.O. Box) City State Zip Code. 9. E-mail Address 10. Home Phone Number 11. Work Phone Number 12. Application for Admission Instructions: Please print or type a response to each question. All documents submitted to the college become part of the official files and cannot be returned. (use black ink)

More information

SCHOLARSHIPS. Pre-Qualification and Application Form

SCHOLARSHIPS. Pre-Qualification and Application Form & Sc h o l a r s h i p s In c e n t i v e s SCHOLARSHIPS Pre-Qualification and Application Form Bright from the Start: Georgia Department of Early Care and Learning is proud to support and encourage Georgia

More information

HURRICANE IKE INTAKE APPLICATION

HURRICANE IKE INTAKE APPLICATION HURRICANE IKE INTAKE APPLICATION INSTRUCTIONS FOR APPLICATION STEP 1: Read the instructions for this application and the Frequently Asked Questions (FAQ). They contain important information about documents

More information

Child Care Regulations in South Dakota

Child Care Regulations in South Dakota Child Care Regulations in South Dakota Overview A summary of child care regulations in South Dakota Types of care that must be licensed Types of care that must be registered Types of care that may operate

More information

Please note: We are accepting applications for 1-4 bedroom apartments only.

Please note: We are accepting applications for 1-4 bedroom apartments only. Page 1 Gardens at SouthBay Preliminary Application 6720 S. Louis Ave, Tampa, FL 33616 PLEASE RETURN APPLICATION MONDAY THURSDAY 9AM 6PM POR FAVOR DE REGRESAR LA APLICACIÓN DE LUNES A JUEVES DE 9AM A 6PM

More information

APPLICATION FOR THERAPEUTIC MASSAGE THERAPIST LICENSE

APPLICATION FOR THERAPEUTIC MASSAGE THERAPIST LICENSE APPLICATION FOR THERAPEUTIC MASSAGE THERAPIST LICENSE CITY ADMINISTRATOR S OFFICE 1307 Cloquet Avenue, Cloquet MN 55720 Phone: 218-879-3347 Fax: 218-879-6555 www.ci.cloquet.mn.us email: djohnson@ci.cloquet.mn.us

More information

T.E.A.C.H. Early Childhood TEXAS Associate Degree Scholarship Program Application Early Childhood Education/Child Development

T.E.A.C.H. Early Childhood TEXAS Associate Degree Scholarship Program Application Early Childhood Education/Child Development Associate Degree Scholarship Program Early Childhood Education/Child Development Date: Name Address City, State, Zip County Phone Number Home: Work: SSN Email Date of Birth (mm/dd/yyyy) Gender Employment

More information

Important Notice regarding your Family Child Care License Renewal

Important Notice regarding your Family Child Care License Renewal The Commonwealth of Massachusetts Thomas L. Weber, Acting Commissioner Important tice regarding your Family Child Care License Renewal Your Family Child Care License is due for renewal. In order to maintain

More information

UNDERGRADUATE NON-DEGREE ENROLLMENT FORM

UNDERGRADUATE NON-DEGREE ENROLLMENT FORM UNDERGRADUATE NON-DEGREE ENROLLMENT FORM UNDERGRADUATE STUDENTS ONLY: You WILL NOT be eligible for non-degree enrollment if any of the following statements apply to you. If you have: n Previously attended

More information

OFFICE OF PROFESSIONAL DEVELOPMENT

OFFICE OF PROFESSIONAL DEVELOPMENT COLORADO OFFICE OF PROFESSIONAL DEVELOPMENT Empowering & Advancing Early Childhood Professionals OFF PRO DEV Early Childhood Credential Application Packet Colorado Office of Professional Development 1580

More information

2015 Small group new business application

2015 Small group new business application 2015 Small group new business application PLEASE COMPLETE AND RETURN ALL PAGES IN THIS APPLICATION OR PROCESSING COULD BE DELAYED. 1-50 eligible employees New group checklist Use this checklist to expedite

More information

JOB OPPORTUNITY. Firefighter-Fire Department. P.O. Box 635030 Nacogdoches, TX 75963-5030 Office: 936-559-2567 Fax: 936-559-2915

JOB OPPORTUNITY. Firefighter-Fire Department. P.O. Box 635030 Nacogdoches, TX 75963-5030 Office: 936-559-2567 Fax: 936-559-2915 JOB OPPORTUNITY Firefighter-Fire Department P.O. Box 635030 Nacogdoches, TX 75963-5030 Office: 936-559-2567 Fax: 936-559-2915 Firefighter-Nacogdoches Fire & Rescue Nacogdoches Firefighters provides exceptional

More information

Application for Housing

Application for Housing Application for Housing HELP Philadelphia IV consists of sixty 1-BEDROOM units. Applicant Information Last Name First Name MI Street Address Apt. # City State Zip Code Social Security# Home Phone: Date

More information

Maine Roads Scholarship Program CDA Information 2015-2016

Maine Roads Scholarship Program CDA Information 2015-2016 www.muskie.usm.maine.edu/maineroads PLEASE READ BEFORE COMPLETING APPLICATION FORM Maine Roads Scholarship Program CDA Information 2015-2016 I. DEFINITION ki i The Maine Roads Scholarship Program is a

More information

Criminal background and eviction will be check within the past 5 years.

Criminal background and eviction will be check within the past 5 years. Housing Authority of the City of Fort Lauderdale (HACFL) Telephone: (954)556-4100 Submit your application to: HACFL- Affordable Housing Division 500 West Sunrise Boulevard Fort Lauderdale, FL 33311 The

More information

4. Send the completed application and documentation to: In the San Luis Valley, please send all info to:

4. Send the completed application and documentation to: In the San Luis Valley, please send all info to: Colorado Department of Human Services (CDHS) Colorado Early Childhood Professional Credential For Professionals working with children birth to 8 years Directions: 1. Complete pages 2, 3, 4 and 5 of the

More information

MARYLAND BOARD OF PHYSICIANS. Registration and Re-registration Instructions for Unlicensed Medical Practitioners (UMP)

MARYLAND BOARD OF PHYSICIANS. Registration and Re-registration Instructions for Unlicensed Medical Practitioners (UMP) MARYLAND BOARD OF PHYSICIANS Registration and Re-registration Instructions for Unlicensed Medical Practitioners (UMP) Chief of Service - Responsibility The Maryland Annotated Code, Health Occupations 14-302(1)

More information

Patient Care Technician Program

Patient Care Technician Program Workforce and Continuing Education Division Patient Care Technician Program This program prepares a student to work as an entry-level patient care technician in a clinic, hospital, nursing home or long-term

More information

Women s Leadership Council Fall 2016 Young Mother s Daycare Scholarship (Post-Secondary)

Women s Leadership Council Fall 2016 Young Mother s Daycare Scholarship (Post-Secondary) Women s Leadership Council Fall 2016 Young Mother s Daycare Scholarship (Post-Secondary) Statement of Purpose The Women s Leadership Council of Montgomery County United Way (MCUW) is sponsoring this scholarship

More information

An Employment Agency

An Employment Agency NOTICE TO APPLICANTS You may mail your completed application or drop it by the office. Interviews will be scheduled after completed application and reference forms have been returned to the office. Reference

More information

APPLICATION CHECK LIST

APPLICATION CHECK LIST APPLICATION CHECK LIST Full application includes: o Patient Information Form o Household & Family Financial Profiles o Employment/Salary Verification. This form must be signed by the employer o Methodist

More information

SECTION 15 (HIPAA-CHIP) ELIGIBILITY AND ENROLLMENT FORM COMPLETE ALL OF THE FOLLOWING QUESTIONS IN THEIR ENTIRETY (Please print)

SECTION 15 (HIPAA-CHIP) ELIGIBILITY AND ENROLLMENT FORM COMPLETE ALL OF THE FOLLOWING QUESTIONS IN THEIR ENTIRETY (Please print) I C H I P Illinois Comprehensive Health Insurance Plan STATE OF ILLINOIS COMPREHENSIVE HEALTH INSURANCE PLAN (CHIP) 400 West Monroe Street, Suite 202, Springfield, Illinois 62704-1823 1-866-851-2751 (toll-free

More information

T.E.A.C.H. Early Childhood ALABAMA Bachelor Degree Scholarship Application for Child Care Center/Preschool Teachers

T.E.A.C.H. Early Childhood ALABAMA Bachelor Degree Scholarship Application for Child Care Center/Preschool Teachers GENERAL INFORMATION: Social Security Number: - - Date: Name: Address: Apt #: City: State: Zip: County: Phone: Home: ( ) Cell: ( ) Work: ( ) Email Address: Date of Birth (mm/dd/yyyy): / / Gender: Female

More information

Store Use Only: Identification requires a valid driver s license and/or government issued photo ID

Store Use Only: Identification requires a valid driver s license and/or government issued photo ID NTB Credit Card APPLICATION INFORMATION ABOUT YOURSELF First Name Middle Initial Last Name Street Address (No P.O. Boxes) City State Zip Code Home Phone Social Security Number Date of Birth Employer Employer

More information

Maine Roads Scholarship Program Degree Information 2015-2016

Maine Roads Scholarship Program Degree Information 2015-2016 www.muskie.usm.maine.edu/maineroads Maine Roads Scholarship Program Degree Information 2015-2016 PLEASE READ BEFORE COMPLETING APPLICATION FORM I. DEFINITION The Maine Roads Scholarship Program is a financial

More information

Iowa Department of Human Services Application for Food Assistance

Iowa Department of Human Services Application for Food Assistance What is Food Assistance? Iowa Department of Human Services Application for Food Assistance Food Assistance is a program to help buy food for good health. How Do I Get Food Assistance? Step 1. Fill out

More information

Baker County 1995 Third Street Baker City, OR 97814

Baker County 1995 Third Street Baker City, OR 97814 Baker County 1995 Third Street Baker City, OR 97814 (541) 523-8200 An Equal Opportunity Employer Application for Employment (Please Print or Type) Name: Please PRINT or TYPE Last Name, First Name and Middle

More information

Instructions for Completing a Medicare Savings Program (MSP) Application

Instructions for Completing a Medicare Savings Program (MSP) Application Instructions for Completing a Medicare Savings Program (MSP) Application The attached Department of Human Services (DHS) Health Services Application is used to apply for Medicare Savings Programs (MSP)

More information

Tooele County HOMEOWNER HOUSING REHAB LOAN APPLICATION

Tooele County HOMEOWNER HOUSING REHAB LOAN APPLICATION ELIGIBILITY Income Eligibility: This program is available to households with a maximum of 80 percent of the median family income for Tooele County. If your household income is greater than the limits,

More information

The University of the State of New York. THE STATE EDUCATION DEPARTMENT Office of the Professions

The University of the State of New York. THE STATE EDUCATION DEPARTMENT Office of the Professions The University of the State of New York Certified Public Accountant THE STATE EDUCATION DEPARTMENT Office of the Professions Form 1 Division of Professional Licensing Services www.op.nysed.gov Application

More information

The Licensing Division will not process an incomplete application or an application submitted before the application fee is paid

The Licensing Division will not process an incomplete application or an application submitted before the application fee is paid Dear License Applicant: All residential and nonresidential programs required to be licensed under Minnesota Statutes, Chapter 245A, Human Services Licensing Act, must complete a license application, the

More information

Required Attachments for Scholarship Applications (Scholarship applications cannot be processed without the following attachments)

Required Attachments for Scholarship Applications (Scholarship applications cannot be processed without the following attachments) Required Attachments for Scholarship Applications (Scholarship applications cannot be processed without the following attachments) For all Scholarship Applicants (Please attach the following documents)

More information

MEDICAL RADIOLOGIC TECHNOLOGIST CERTIFICATION APPLICATION INFORMATION

MEDICAL RADIOLOGIC TECHNOLOGIST CERTIFICATION APPLICATION INFORMATION MEDICAL RADIOLOGIC TECHNOLOGIST CERTIFICATION APPLICATION INFORMATION PRINT or TYPE all information on the application. Please answer all questions completely, do not leave any blank. Please allow 4 to

More information

Professional Credential Services, Inc.

Professional Credential Services, Inc. Professional Credential Services, Inc. P.O. Box 198689 - Nashville, TN 37219-8689 www.pcshq.com Licensure Application for Occupational Therapists For the Massachusetts Board of Allied Health Professionals

More information

Housing Rehabilitation Program Preliminary Application City of Arlington 501 W. Sanford Street, Suite 20 Arlington, Texas 76011

Housing Rehabilitation Program Preliminary Application City of Arlington 501 W. Sanford Street, Suite 20 Arlington, Texas 76011 Date of Application (Office Stamp Only) Housing Rehabilitation Program Preliminary Application City of Arlington 501 W. Sanford Street, Suite 20 Arlington, Texas 76011 The information collected below will

More information