BACKGROUND INFORMATION DISCLOSURE (BID)

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "BACKGROUND INFORMATION DISCLOSURE (BID)"

Transcription

1 DEPARTMENT OF CHILDREN AND FAMILIES DCF-F-2978-E (R. 06/2016) BACKGROUND INFORMATION DISCLOSURE (BID) STATE OF WISCONSIN Wis. Stat Wis. Admin. Code DCF Completion of this form is required under the provisions of Wis. Stat and Wis. Admin. Code DCF Pursuant to Wis. Stat , this form must be completed prior to licensure, certification, employment or non-client residency and is only valid for 120 days. Failure to comply may result in a denial or revocation of your license or certification; denial or termination of your employment or contract; or denial or revocation of the license or certification for a child care center location at which you reside. Providing your social security number (SSN) is voluntary; not providing it could result in an information processing delay. Personal information you provide may be used for secondary purposes [Privacy Law, Wis. Stat (1)(m)]. PLEASE PRINT OR TYPE YOUR ANSWERS. ATTACH ADDITIONAL PAGES IF NEEDED. Check the box that applies to you. Current or Prospective Employee / Contractor Applicant for a license or certification (including continuation or renewal) Household member / lives on premises but not a client (anyone 12 years of age and over). Other Specify: Name (First and Middle) Name (Last) Position Title (If applicable) Any Other Names By Which You Have Been Known (Including Maiden Name) Birth Date Gender (M / F) Race Social Security Number(s) American Indian or Alaskan Native Black Unknown Asian or Pacific Islander White Home Address City State Zip Code Name and address of Potential Employer, Licensing Agency, Certifying Agency, or the child care center at which you reside or will reside. SECTION A ACTS, CRIMES, AND OFFENSES THAT MAY ACT AS A BAR OR RESTRICTION YES NO 1. Do you have any criminal charges pending against you or were you ever convicted of any crime anywhere, including in federal, state, county, local, military, and tribal courts? Have you ever been convicted of another offense such as a municipal ordinance violation or a civil offense under a local ordinance? If Yes, list each pending charge or conviction, when it occurred, the date or arrest and conviction if applicable, and the city and state where the court is located. You may be asked to supply additional information including certified copy of the judgment of conviction, a copy of the criminal complaint or any other relevant court or police documents. 2. Were you ever adjudicated delinquent by a court of law, including tribal court, on or after your 12 th birthday and before your 18 th birthday, for a crime or other offense such as a municipal ordinance violation or a civil offense under a local ordinance? If Yes, list each crime or offense, when and where it happened, and the location of the court (city and state). You may be asked to supply additional information including a certified copy of the delinquency petition, the delinquency adjudication, or any other relevant court or police documents. 3. Are you currently under community supervision by a state, federal or tribal agency (i.e. probation, extended supervision or parole)? If Yes, provide the name, address and phone number of the agency. 4. Are you currently, or have you ever been, required to be registered on a state, tribal or national sex offender registry? If Yes, explain, including the location, reason for registration and length of time required to be registered.

2 Page 2 of 3 Last Name SECTION A ACTS, CRIMES, AND OFFENSES THAT MAY ACT AS A BAR OR RESTRICTION YES NO 5. Are you currently the subject of a child abuse or neglect investigation by a government or regulatory agency? If Yes, explain and provide the name of the agency conducting the investigation. 6. Has any government or regulatory agency (other than the police) ever found that you abused or neglected a child? If Yes, explain, including when and where it happened and the name of the agency that made the finding. 7. Has any government or regulatory agency (other than the police) ever found that you abused or neglected any person or client? 8. Has any government or regulatory agency (other than the police) ever found that you misappropriated (improperly took or used) the property of a person or client? 9. Has any government or regulatory agency (other than the police) ever found that you abused an elderly person? 10. Do you have a government issued credential that is not current or is limited so as to restrict you from providing care to clients? If Yes, explain, including credential name, limitations or restrictions, and time period. SECTION B OTHER REQUIRED INFORMATION YES NO 1. Has any government or regulatory agency ever limited, denied, or revoked your license, certification, or registration to provide care, treatment, or educational services? 2. Has any government or regulatory agency ever denied you permission or restricted your ability to live on the premises of a care providing facility? If Yes, explain, including when and where it happened and the reason. 3. Have you been discharged from a branch of the U.S. Armed Forces, including any reserve component? If yes, indicate the year of discharge: Attach a copy of your DD214 if you were discharged within the last 3 years. 4. Have you resided outside of Wisconsin in the last 5 years? If Yes, list each state and the dates you lived there.

3 Page 3 of 3 Last Name SECTION B OTHER REQUIRED INFORMATION YES NO 5. Have you had a caregiver background check done within the last 4 years? If Yes, list the date of each check, and the name, address, and phone number of the person, facility, or government agency that conducted each check. 6. Have you ever requested a rehabilitation review with the Wisconsin Department of Health Services or the Department Children and Families, a county department, a private child placing agency, school board or tribe? If Yes, list the review date, the result, the agency that conducted the review and attach a copy of the review decision. A NO answer to all questions does not guarantee employment, residency, a contract, or regulatory approval. I understand, under penalty of law that the information provided above is truthful and accurate to the best of my knowledge. I understand that knowingly providing false information or omitting information may result in a forfeiture and other sanctions as provided by law. SIGNATURE Date Signed

4 Consent for Release of Confidential Information Form Instructions Every individual age 12 years and older who completes a Background Information Disclosure Form must also complete the attached Consent for Release of Confidential Information Form. This form allows 4-C to perform a social service check with Dane, Columbia, Rock, and Walworth County Human Services. When completing this form, please make sure to: 1. Fill out the name, date of birth, and address boxes in the upper right corner of the form. 2. Sign and date the bottom. If the individual is a minor, a parent or guardian can sign in the lower box. If you have any questions about this form, please contact 4-C at

5 CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION INCLUDING PROTECTED HEALTH INFORMATION Name-Individual Who is Subject of Record Address Date of Birth Right to Copy and Inspect: If records regarding medical treatment or treatment for mental illness, developmental disabilities, alcoholism, or drug abuse are disclosed pursuant to this authorization, you may have the right to inspect and, upon paying any applicable fees, obtain a copy of the records disclosed. City, State, Zip Code Name and Address of Person/Agency Authorized to Release Information: >Columbia, Dane, Rock, & Walworth County Human Services Name and Address of Person/Agency Information May be Released to: >4-C Certification 5 Odana Ct. Madison, WI Specific Records Authorized for Release: Complete copy of the medical records specified below: Immunization records Diagnostic and treatment records Discharge summaries Lab reports HIV/AIDS diagnostic and treatment records Out-patient notes Other Alcohol and drug abuse evaluation and treatment records Mental health diagnostic and treatment records Child protective and delinquency services records Social services records Law enforcement records Juvenile court records Education records, including behavior, progress, pupil, and Individual Education Plan (I.E.P.) records Other For the following dates: All files/records pertaining to person indicated above. Purpose for Release of Information: Eligibility for in-home family child care certification. The person above is either a resident in the home and/or someone who may have contact with day care children. Voluntary Consent: My consent to the release of the confidential records described above is voluntarily given. Refusal to sign this authorization will not affect my right to receive health care or payment of claims except as provided by law. Expiration Date or Event: This authorization expires one (1) year from the date of my signature. Right to revoke: I understand that I may revoke this authorization at any time, except where information has already been released pursuant to this authorization, by sending a written notice of my revocation to the individual/agency hereby authorized to release information. Unless so revoked, this authorization will remain in effect until the expiration event indicated above. Notice of re-release: Information from the confidential records released hereby may be re-released to the juvenile court and shared with the guardian ad litem or attorney for your child, your attorney, the attorney for any other party to the proceeding before the court and the court appointed special advocate for your child. The information may be further released to any court appointed evaluator or court ordered service provider(s). As evidenced by my signature, I hereby authorize disclosure of the confidential records described above to the person(s) or agency(s) specified above. Signature (Adult Subject of Record) Date Signed Signature (Parent or Guardian) Date Signed Title or Relationship to Individual who is Subject of Record Original - DCDHS client file Rev. 11/09 Copy - Client

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

REHABILITATION REVIEW APPLICATION INSTRUCTIONS

REHABILITATION REVIEW APPLICATION INSTRUCTIONS DEPARTMENT OF HEALTH SERVICES Office of Legal Counsel F-83263 (05/2014) STATE OF WISCONSIN REHABILITATION REVIEW APPLICATION INSTRUCTIONS The Rehabilitation Review Application consists of eight sections,

More information

Accelerated Online Bachelor s to BSN Option Application Information and Forms: May 2012 Cohort

Accelerated Online Bachelor s to BSN Option Application Information and Forms: May 2012 Cohort Accelerated Online Bachelor s to BSN Option Application Information and Forms: May 2012 Cohort Please read the entire application before completing it. To apply, please complete all forms in this application

More information

To ensure your application is complete we will check your application with this list to make sure you ve done the following:

To ensure your application is complete we will check your application with this list to make sure you ve done the following: To ensure your application is complete we will check your application with this list to make sure you ve done the following: Read the first page if you understand and agree sign and date it at the bottom.

More information

THOROUGHBRED RACING VENDOR LICENSE FORM

THOROUGHBRED RACING VENDOR LICENSE FORM THOROUGHBRED RACING VENDOR LICENSE FORM Name of Applicant: ----------OFFICE USE ONLY---------- Date: License Year: License.: Cash: / Check.: Credit Card Amount: Total Fees Received: Reviewer: New Renewal

More information

STATE OF TENNESSEE EMPLOYMENT APPLICATION

STATE OF TENNESSEE EMPLOYMENT APPLICATION USE BLACK INK ONLY TO COMPLETE THIS APPLICATION FORM. REQUIRED FIELDS OR YOUR APPLICATION WILL BE RETURNED TO YOU. PLEASE COMPLETE ALL Please record your Social Security Number below. List the specific

More information

Accelerated Online Bachelor s to BSN Option Application Information and Forms: October 2015 Cohort

Accelerated Online Bachelor s to BSN Option Application Information and Forms: October 2015 Cohort Accelerated Online Bachelor s to BSN Option Application Information and Forms: October 2015 Cohort Please read this entire application packet before completing the application. To apply, please submit

More information

APPLICANT INFORMATION (please print or type)

APPLICANT INFORMATION (please print or type) STATE OF MINNESOTA DEPARTMENT OF COMMERCE 85 7 TH PLACE EAST, SUITE 600 ST. PAUL, MINNESOTA 55101 (651) 539-1599 (For Department Use Only) DESIGNATED HOME STATE BUSINESS ENTITY INSURANCE ADJUSTER LICENSE

More information

APPLICANT INFORMATION (please print or type)

APPLICANT INFORMATION (please print or type) STATE OF MINNESOTA DEPARTMENT OF COMMERCE 85 7 TH PLACE EAST, SUITE 600 ST. PAUL, MINNESOTA 55101 (651) 539-1599 (For Department Use Only) TRAVEL INSURANCE PRODUCER BUSINESS ENTITY LICENSE APPLICATION

More information

University of Michigan Health System Background Check Information, Consent and Disclosure

University of Michigan Health System Background Check Information, Consent and Disclosure University of Michigan Health System Background Check Information, Consent and Disclosure The University of Michigan Health System assures the integrity of its workforce and protects its patients in part

More information

LONG TERM CARE WORKFORCE BACKGROUND CHECK CONSENT AND DISCLOSURE

LONG TERM CARE WORKFORCE BACKGROUND CHECK CONSENT AND DISCLOSURE STATE OF MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS DEPARTMENT OF HUMAN SERVICES LONG TERM CARE WORKFORCE BACKGROUND CHECK CONSENT AND DISCLOSURE Part 1 Consent Part 2 Applicant Information

More information

APPLICATION FOR A YACHT AND SHIP EMPLOYING BROKER, BROKER OR SALESPERSON'S LICENSE

APPLICATION FOR A YACHT AND SHIP EMPLOYING BROKER, BROKER OR SALESPERSON'S LICENSE APPLICATION FOR A YACHT AND SHIP EMPLOYING BROKER, BROKER OR SALESPERSON'S LICENSE Attached please find the application for a yacht and ship employing broker, broker or salesperson's license. Once received,

More information

Relationship to Victim. Mailing Address City/State/Zip. SSN Date of Birth. Home Telephone Cell phone Other. Email address

Relationship to Victim. Mailing Address City/State/Zip. SSN Date of Birth. Home Telephone Cell phone Other. Email address State of Alaska Violent Crimes Compensation Board Application for Crime Victim Compensation Application for Crime Victim Compensation Section 1 Claimant A separate application must be completed for each

More information

STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH ASBESTOS Worker and Supervisor Application

STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH ASBESTOS Worker and Supervisor Application STATE OF CONNECTICUT ASBESTOS Worker and Supervisor Application General Policies and Procedures IMPORTANT: THE DEPARTMENT WILL NOT REVIEW HAND-DELIVERED APPLICATIONS AT THE TIME OF RECEIPT. PROFESSIONAL

More information

Criminals; Rehabilitation CHAPTER 364 CRIMINAL OFFENDERS; REHABILITATION

Criminals; Rehabilitation CHAPTER 364 CRIMINAL OFFENDERS; REHABILITATION 1 MINNESOTA STATUTES 2013 364.02 Criminals; Rehabilitation CHAPTER 364 CRIMINAL OFFENDERS; REHABILITATION 364.01 POLICY. 364.02 DEFINITIONS. 364.021 PUBLIC AND PRIVATE EMPLOYMENT; CONSIDERATION OF CRIMINAL

More information

Wisconsin Department of Safety and Professional Services

Wisconsin Department of Safety and Professional Services Mail To: P.O. Box 8935 Ship To: 1400 E. Washington Avenue Madison, WI 53708-8935 Madison, WI 53703 FAX #: (608) 261-7083 E-Mail: dsps@wisconsin.gov Phone #: (608) 266-2112 Website: http://dsps.wi.gov BOARD

More information

Renewal Application Instructions & Requirements

Renewal Application Instructions & Requirements Certification Office 800 Governors Drive Pierre, South Dakota 57501 certification@state.sd.us Telephone: 605.773.3426 Renewal Application Instructions & Requirements Five-year renewal All credits must

More information

VOLUNTEER APPLICATION

VOLUNTEER APPLICATION CASA of Los Angeles Member National Court Appointed Special Advocate Association 201 Centre Plaza Drive Suite 1100 Monterey Park, California 91754 Phone 323-859-2888 Fax 323-264-5020 www.casala.org VOLUNTEER

More information

Application for Employment

Application for Employment Application for Employment Date of Application: PERSONAL INFORMATION NAME: LAST FIRST M.I. MAIDEN NAME ADDRESS: PHYSICAL ADDRESS CITY STATE ZIP CODE Do you have the legal right to work in the United States?

More information

FIRE FIGHTER APPLICATION PACKAGE

FIRE FIGHTER APPLICATION PACKAGE FIRE FIGHTER APPLICATION PACKAGE APPLICATION CLOSING DATE AND LOCATION: TUESDAY, NOVEMBER 8, 2011 AT 5:00 P.M. (CENTRAL STANDARD TIME) HUMAN RESOURCES DEPARTMENT 1110 HOUSTON STREET, LAREDO, TEXAS 78042

More information

STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH ASBESTOS Contractor License Application

STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH ASBESTOS Contractor License Application STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH ASBESTOS Contractor License Application General Policies and Procedures IMPORTANT: THE DEPARTMENT WILL NOT REVIEW HAND-DELIVERED APPLICATIONS AT THE TIME

More information

INFORMATION/INSTRUCTION SHEET CERTIFIED PODIATRIC X-RAY ASSISTANT

INFORMATION/INSTRUCTION SHEET CERTIFIED PODIATRIC X-RAY ASSISTANT Chapter 461, Florida Statutes Rule Chapter 64B18-24, Florida Administrative Code INFORMATION/INSTRUCTION SHEET CERTIFIED PODIATRIC X-RAY ASSISTANT Any Certified Podiatric X-ray Assistant may perform services

More information

Wisconsin Department of Safety and Professional Services

Wisconsin Department of Safety and Professional Services Mail To: P.O. Box 8935 1400 E. Washington Avenue Madison, WI 53708-8935 Madison, WI 53703 FAX #: (608) 261-7083 E-Mail: web@dsps.wi.gov Phone #: (608) 266-2112 Website: http://dsps.wi.gov PSYCHOLOGY EXAMINING

More information

REGISTRATION AUTISM TREATMENT SERVICES

REGISTRATION AUTISM TREATMENT SERVICES 559 Zor Shrine Place Madison, WI 53719 P: 608.833.0123 F: 608.833.0126 www.ids -wi.com CLIENT INFORMATION (First, MI, Last) (Street, City, State, Zip) REGISTRATION AUTISM TREATMENT SERVICES of Birth Home

More information

Quincy Police Department One Sea Street Quincy, MA 02169 (617) 479-1212 TTY: (617) 376-1375

Quincy Police Department One Sea Street Quincy, MA 02169 (617) 479-1212 TTY: (617) 376-1375 PAUL KEENAN CHIEF OF POLICE Quincy Police Department One Sea Street Quincy, MA 02169 (617) 479-1212 TTY: (617) 376-1375 Please complete the attached Firearms Application. All questions must be answered

More information

NOTE: All mailings will be sent to the address you indicate below; if you change your address, you must advise this office.

NOTE: All mailings will be sent to the address you indicate below; if you change your address, you must advise this office. ATTACHMENT G 7/2013 STATE OF NEBRASKA Department of Health and Human Services Division of Public Health - Licensure Unit P.O. Box 94986 - Lincoln, Nebraska 68509-4986 Telephone #: 402-471-4918 Rita.watson@nebraska.gov

More information

APPLICATION FOR: ARD DUI Fee due with application - $300 ARD non DUI Fee due with application - $0 Criminal Complaint must be attached.

APPLICATION FOR: ARD DUI Fee due with application - $300 ARD non DUI Fee due with application - $0 Criminal Complaint must be attached. COMMONWEALTH OF PENNSYLVANIA APPLICATION FOR: ARD DUI Fee due with application - $300 ARD non DUI Fee due with application - $0 Criminal Complaint must be attached VS NO20 CR DEFENDANT S WAIVER OF RULE

More information

The High Cost of DWI. Ignition interlock license available 66-5-503 7

The High Cost of DWI. Ignition interlock license available 66-5-503 7 The High Cost of DWI In New Mexico 2007-2008 The New Mexico Department of Transportation, Traffic Safety Bureau Offense Jail 1 Fines and Fees 2 License Revocation 1 st 90 days 48 hours if offender fails

More information

COLLATERAL CONSEQUENCES OF JUVENILE ADJUDICATIONS OF DELINQUENCY

COLLATERAL CONSEQUENCES OF JUVENILE ADJUDICATIONS OF DELINQUENCY COLLATERAL CONSEQUENCES OF JUVENILE ADJUDICATIONS OF DELINQUENCY This document is meant to provide general information about the collateral consequences of juvenile adjudications. This document is not

More information

APPRAISAL MANAGEMENT COMPANY RENEWAL APPLICATION

APPRAISAL MANAGEMENT COMPANY RENEWAL APPLICATION Complete, sign, and submit this form along with the items listed below to the Division. Entity Name: Email: Business Address: City: State: Zip: Ph: Fax: Registered Agent: Email: City: State: Zip: Ph: Fax:

More information

State of Oregon - Board of Licensed Social Workers 3218 Pringle Rd. SE, Ste. 240, Salem, OR 97302 (503) 378-5735 Oregon.BLSW@state.or.

State of Oregon - Board of Licensed Social Workers 3218 Pringle Rd. SE, Ste. 240, Salem, OR 97302 (503) 378-5735 Oregon.BLSW@state.or. State of Oregon - Board of Licensed Social Workers 3218 Pringle Rd. SE, Ste. 240, Salem, OR 97302 (503) 378-5735 Oregon.BLSW@state.or.us LCSW License Renewal Application License Number: Renewal Date (end

More information

Wisconsin Department of Safety and Professional Services

Wisconsin Department of Safety and Professional Services Mail To: P.O. Box 8935 1400 E. Washington Avenue Madison, WI 53708-8935 Madison, WI 53703 FAX #: (608) 261-7083 E-Mail: web@dsps.wi.gov Phone #: (608) 266-2112 Website: http://dsps.wi.gov PODIATRY AFFILIATED

More information

APPLICATION FOR ADDICTION COUNSELOR TRAINEE RECOGNITION OR ADDICTION COUNSELOR TRAINEE RENEWAL

APPLICATION FOR ADDICTION COUNSELOR TRAINEE RECOGNITION OR ADDICTION COUNSELOR TRAINEE RENEWAL Board of Addiction and Prevention Professionals (BAPP) 3101 West 41 st Street, Suite 205, Sioux Falls, SD 57105 Phone: 605-332-2645 Fax: 605-332-6778 Email: bapp@midconetwork.com Web: www.dss.sd.gov/bapp

More information

APPLICATION FOR A PEDDLER, SOLICITOR OR TRANSIENT MERCHANT LICENSE. Fee $60 per Solicitor

APPLICATION FOR A PEDDLER, SOLICITOR OR TRANSIENT MERCHANT LICENSE. Fee $60 per Solicitor CITY OF FRIDLEY 6431 UNIVERSITY AVENUE NE FRIDLEY, MN 55432 763-572-3523 www.fridleymn.gov Check # License # Expiration April 30, APPLICATION FOR A PEDDLER, SOLICITOR OR TRANSIENT MERCHANT LICENSE Business

More information

Application. Minnesota Crime Victims Reparations Board

Application. Minnesota Crime Victims Reparations Board Application Minnesota Crime Victims Reparations Board The Minnesota Crime Victims Reparations Board provides financial assistance to victims of violent crime and their family members for related expenses

More information

Applicants will be notified within 15 working days of receipt of a completed application as to the status of the application.

Applicants will be notified within 15 working days of receipt of a completed application as to the status of the application. 2/09, 03/11, 11/11, 01/13, 01/15 Page 1 of 10 MONTANA BOARD OF RADIOLOGIC TECHLOGISTS 301 SOUTH PARK, 4TH FLOOR PO BOX 200513 HELENA, MONTANA 59620-0513 (406) 841-2202 FAX: (406) 841-2305 email: dlibsdrts@mt.gov

More information

Department of Education Alternative Route to Certification Program Application

Department of Education Alternative Route to Certification Program Application Certification Office 800 Governors Drive Pierre, South Dakota 57501 certification@state.sd.us Telephone: 605.773.3426 Department of Education Alternative Route to Certification Program Application Instructions

More information

MONTGOMERY YMCA APPLICATION FOR EMPLOYMENT

MONTGOMERY YMCA APPLICATION FOR EMPLOYMENT RETURN TO BRANCH: MONTGOMERY YMCA APPLICATION FOR EMPLOYMENT YMCA Mission To put Christian principles into practice through programs that build a healthy body, mind and spirit for all. Equal Opportunity

More information

Montana Application for Class 6 Specialist License School Psychologist Endorsement

Montana Application for Class 6 Specialist License School Psychologist Endorsement Montana Application for Class 6 Specialist License School Psychologist Endorsement Requirements for Montana Class 6 School Psychologist Specialist license 1. Verification of current credentials as a nationally

More information

State of Oklahoma COUNCIL ON LAW ENFORCEMENT EDUCATION AND TRAINING INDIVIDUAL LICENSE SUPPLEMENT

State of Oklahoma COUNCIL ON LAW ENFORCEMENT EDUCATION AND TRAINING INDIVIDUAL LICENSE SUPPLEMENT State of Oklahoma COUNCIL ON LAW ENFORCEMENT EDUCATION AND TRAINING INDIVIDUAL LICENSE SUPPLEMENT LATE RENEWAL - SIX MONTHS TO TWO YEARS LATE 1. Complete this supplement. 2. Provide local record checks

More information

Filing Fee $117.00. Instructions for Sealing a Criminal Record

Filing Fee $117.00. Instructions for Sealing a Criminal Record Filing Fee $117.00 Instructions for Sealing a Criminal Record Effective 1-1-2015 This packet is to be used to assist you in filing an application to seal your criminal record. * * * * * * * * * * * * *

More information

POLICE OFFICER EMPLOYMENT APPLICATION PLATTEVILLE POLICE DEPARTMENT 165 N. Fourth Street Platteville, Wisconsin 53818 (608) 348-2313

POLICE OFFICER EMPLOYMENT APPLICATION PLATTEVILLE POLICE DEPARTMENT 165 N. Fourth Street Platteville, Wisconsin 53818 (608) 348-2313 POLICE OFFICER EMPLOYMENT APPLICATION PLATTEVILLE POLICE DEPARTMENT 165 N. Fourth Street Platteville, Wisconsin 53818 (608) 348-2313 IMPORTANT INSTRUCTIONS: This application must be completely filled out

More information

ASSOCIATE BROKER STANDARD INITIAL LICENSE APPLICATION

ASSOCIATE BROKER STANDARD INITIAL LICENSE APPLICATION STATE REAL ESTATE COMMISSION PO Box 2649 Harrisburg PA 17105-2649 Phone Number 717-783-3658 Fax Number: 717-787-0250 www.dos.pa.gov/estate ASSOCIATE BROKER STANDARD INITIAL LICENSE APPLICATION Make sure

More information

Wisconsin Department of Safety and Professional Services

Wisconsin Department of Safety and Professional Services Mail To: P.O. Box 8935 1400 E. Washington Avenue Madison, WI 53708-8935 Madison, WI 53703 FAX #: (608) 261-7083 E-Mail: web@dsps.wi.gov Phone #: (608) 266-2112 Website: http://dsps.wi.gov BOARD OF NURSING

More information

FINGERPRINT BACKGROUND CHECK

FINGERPRINT BACKGROUND CHECK APPLICATION FOR LICENSURE PHARMACY TECHNICIAN (Non-Renewable: Expires the second June 30 from the date of issuance) OR CERTIFIED OREGON PHARMACY TECHNICIAN (Renewable: Expires September 30 th Annually)

More information

STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH LEAD Contractor License Application

STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH LEAD Contractor License Application STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH LEAD Contractor License Application General Policies and Procedures IMPORTANT: THE DEPARTMENT WILL NOT REVIEW HAND-DELIVERED APPLICATIONS AT THE TIME OF

More information

APPLICATION FOR LICENSURE AS A PSYCHOLOGIST

APPLICATION FOR LICENSURE AS A PSYCHOLOGIST APPLICATION FOR LICENSURE AS A PSYCHOLOGIST Application Fee: $40 (Nonrefundable) File #: SECTION I. PErSONAl DATA (Board use only) Last First Middle Initial Jr., Sr., I, II (Note: Formal identification

More information

Application for Employment

Application for Employment ANGELA B. COREY ST AT E A TT ORNEY STATE ATTORNEY Fourth Judicial Circuit of Florida Ed Austin Building 311 West Monroe Street Jacksonville, Florida 32202-4242 Tel: (904) 255-2500 Fax: (904) 255-2942 Application

More information

HEALTH LICENSING OFFICE Respiratory Therapist Polysomnographic Technologist Licensing Board

HEALTH LICENSING OFFICE Respiratory Therapist Polysomnographic Technologist Licensing Board HEALTH LICENSING OFFICE Respiratory Therapist Polysomnographic Technologist Licensing Board 700 Summer St. NE, Suite 320, Salem, OR, 97301 Phone: 503-378-8667 Fax: 503-370-9004 www.oregon.gov/oha/hlo Email:

More information

Harris County - Texas HIPAA Notice of Privacy Practices

Harris County - Texas HIPAA Notice of Privacy Practices Harris County - Texas HIPAA Notice of Privacy Practices Effective Date: September 23, 2013. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS

More information

Criminal Justice Institute

Criminal Justice Institute May 22, 2014 Dear Student: Thank you for your interest in obtaining your Florida certification as a law enforcement or correctional officer. The Equivalency-of-Training process enables one to become exempt

More information

LP License Expires 90 days from date of NBCOT Eligibility to Test Letter PERSONAL INFORMATION EDUCATION LICENSURE & HISTORY INFORMATION

LP License Expires 90 days from date of NBCOT Eligibility to Test Letter PERSONAL INFORMATION EDUCATION LICENSURE & HISTORY INFORMATION Oregon Occupational Therapy Licensing Board State Office Building, 800 NE Oregon St., Suite 407 Portland, OR 97232 www.otlb.state.or.us Phone: 971-673-0198 FAX: 971-673-0226 Felicia Holgate, Director Felicia.M.Holgate@state.or.us

More information

Accelerated Online Bachelor s to BSN Option Application Information and Forms: May Cohort

Accelerated Online Bachelor s to BSN Option Application Information and Forms: May Cohort Accelerated Online Bachelor s to BSN Option Application Information and Forms: May Cohort Please read this entire application packet before completing the application. To apply, please submit the required

More information

! EMPLOYMENT APPLICATION

! EMPLOYMENT APPLICATION ! EMPLOYMENT APPLICATION The Lucky Star and Feather Warrior Casinos are Equal Opportunity Employers and will not discriminate against an applicant or employee on any grounds protected under federal, state,

More information

Board of Speech-Language Pathology and Audiology

Board of Speech-Language Pathology and Audiology Board of Speech-Language Pathology and Audiology Application for Speech-Language Pathology or Audiology Provisional Licensure With Instructions Attached Board of Speech-Language Pathology and Audiology

More information

Reason(s) For Referral: Current medications:

Reason(s) For Referral: Current medications: 1540 Sunday Drive Suite 200Raleigh, NC 27607 Office: 919-859-9040FAX: 919-859-9030 Name: Date Examined: Responsible Person: _ Birth Date: Address: Age: Sex: M F Marital Status: S M D W SSN: Home Phone:

More information

Section A Victim/Applicant Information (A separate application must be completed for each victim.)

Section A Victim/Applicant Information (A separate application must be completed for each victim.) Application For Crime Victim Compensation Claim No. Arkansas Crime Victims Reparations Board 323 Center Street, Suite 200 Little Rock, Arkansas 72201 Office of the (501) 682-1020 or 1-800-448-3014 This

More information

NOTICE TO GRANDPARENT

NOTICE TO GRANDPARENT A Power of Atrney may be created if the parent, guardian, or cusdian of the child is any of the following: 1. Seriously ill, incarcerated, or about be incarcerated 2. Temporarily unable provide financial

More information

BEFORE THE COMMISSIONER OF INSURANCE OF THE STATE OF KANSAS

BEFORE THE COMMISSIONER OF INSURANCE OF THE STATE OF KANSAS BEFORE THE COMMISSIONER OF INSURANCE OF THE STATE OF KANSAS In the Matter of the Kansas Nonresident ) Insurance Agent s License of ) Docket No. 3244-SO MICHAEL M. McCAULLEY ) CONSENT ORDER The Kansas Insurance

More information

TECHNICIAN-IN-TRAING IS NOT PERMITTED TO PRACTICE IN MONTANA IN ANY MANNER WITHOUT AN ACTIVE MONTANA REGISTRATION

TECHNICIAN-IN-TRAING IS NOT PERMITTED TO PRACTICE IN MONTANA IN ANY MANNER WITHOUT AN ACTIVE MONTANA REGISTRATION Page 1 of 8 MONTANA BOARD OF PHARMACY (301 S PARK, 4 TH FLOOR, HELENA, MT 59601 - Delivery) P. O. Box 200513 Helena, Montana 59620-0513 PHONE (406) 841-2300 FAX (406) 841-2344 E-MAIL: dlibsdpha@mt.gov

More information

EMPLOYMENT APPLICATION An Equal Opportunity Affirmative Action Employer

EMPLOYMENT APPLICATION An Equal Opportunity Affirmative Action Employer Waukesha County Technical College 800 Main Street, Pewaukee, WI 53072 EMPLOYMENT APPLICATION An Equal Opportunity Affirmative Action Employer Position(s) Applied For Full Time Part Time Name Last First

More information

Polk Medical Center Notice of Privacy Practices

Polk Medical Center Notice of Privacy Practices Polk Medical Center Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

More information

APPLICATION for Graduate Admission

APPLICATION for Graduate Admission APPLICATION for Graduate Admission E. Craig Wall Sr. College of Business Administration Introduction Thank you for your interest in the graduate business programs at Coastal Carolina University. The Master

More information

JOINT NOTICE OF PRIVACY PRACTICES Cumberland County Hospital System d/b/a Cape Fear Valley Health System

JOINT NOTICE OF PRIVACY PRACTICES Cumberland County Hospital System d/b/a Cape Fear Valley Health System JOINT NOTICE OF PRIVACY PRACTICES Cumberland County Hospital System d/b/a Cape Fear Valley Health System EFFECTIVE: September 23, 2013 THIS JOINT NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT

More information

Nj Victims of Crime Compensation Office

Nj Victims of Crime Compensation Office Nj Victims of Crime Compensation Office Claim Information and Application Instructions New Jersey has a Crime Victim s Compensation Fund to help with costs related to injuries received in a violent crime.

More information

New Mexico Office of Superintendent of Insurance Producer Licensing Bureau

New Mexico Office of Superintendent of Insurance Producer Licensing Bureau PLEASE PRINT LEGIBLY OR TYPE Have you held an insurance license in any state within the last 5 years? Yes No If yes, identify the state Demographic Information 1 Soc. Security Number 2 If assigned, National

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

PERSONAL INFORMATION - Please list full legal name as it appears on your Social Security card. Name: Last First Middle Initial

PERSONAL INFORMATION - Please list full legal name as it appears on your Social Security card. Name: Last First Middle Initial Updated 11/2015 Midstate Independent Living Consultants, Inc. 3262 Church Street, Stevens Point, WI 54481 715-344-4210 V/TTY 800-382-8484 V/TTY 715-344-4414 FAX -------------------------------------------------------------------------------------------------

More information

For any questions contact: City Clerk Michelle Tesser Tel: 651-450-2513 Fax: 651-259-8023 mtesser@invergroveheights.org

For any questions contact: City Clerk Michelle Tesser Tel: 651-450-2513 Fax: 651-259-8023 mtesser@invergroveheights.org INSTRUCTIONS FOR THE APPLICATION OF MASSAGE THERAPIST LICENSE THERAPEUTIC MASSAGE BUSINESS LICENSE City of Inver Grove Heights 8150 Barbara Ave, Inver Grove Heights, MN 55077 (651) 450-2500 Fax (651) 450-2502

More information

Employer Instructions for Use ODH Form 805 Uniform Employment Application for Nurse Aide Staff

Employer Instructions for Use ODH Form 805 Uniform Employment Application for Nurse Aide Staff Effective November 1, 2012 Employer Instructions for Use ODH Form 805 Uniform Employment Application for Nurse Aide Staff Purpose This form is to be used by employers as the only employment application

More information

Online Teacher License Application Directions for Adding on a New License. Pre-application process

Online Teacher License Application Directions for Adding on a New License. Pre-application process Online Teacher License Application Directions for Adding on a New License Pre-application process New License Approval Request to UWSP Office of Field Experiences Follow the directions on the UWSP website

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

INSTRUCTION TO APPLICANTS FOR LICENSURE AS A OCCUPATIONAL THERAPIST OR OCCUPATIONAL THERAPY ASSISTANT

INSTRUCTION TO APPLICANTS FOR LICENSURE AS A OCCUPATIONAL THERAPIST OR OCCUPATIONAL THERAPY ASSISTANT INSTRUCTION TO APPLICANTS FOR LICENSURE AS A OCCUPATIONAL THERAPIST OR OCCUPATIONAL THERAPY ASSISTANT A. TEMPORARY LICENSE (90 DAYS)- Applicant must submit the following: Temporary licenses are valid for

More information

Ohio Victims of Crime Compensation Program

Ohio Victims of Crime Compensation Program Ohio Victims of Crime Compensation Program Application for Compensation If you or your family members are innocent victims of a violent crime, financial assistance may be available. The Ohio Victims of

More information

OFFICE OF THE DISTRICT ATTORNEY Third Judicial District Of Kansas Chadwick J. Taylor, District Attorney

OFFICE OF THE DISTRICT ATTORNEY Third Judicial District Of Kansas Chadwick J. Taylor, District Attorney OFFICE OF THE DISTRICT ATTORNEY Third Judicial District Of Kansas Chadwick J. Taylor, District Attorney Shawnee County Courthouse Fax: (785) 251-4909 200 SE 7th Street, Suite 214 Family Law Fax: (785)

More information

Ohio Victims of Crime Compensation Program Application for Crime Victim Compensation

Ohio Victims of Crime Compensation Program Application for Crime Victim Compensation Ohio Victims of Crime Compensation Program Application for Crime Victim Compensation Please type or print using blue or black ink After an application has been filed, the law may provide for payment of

More information

Criminal Justice Selection Center

Criminal Justice Selection Center Send all mail to: Gulf Coast Criminal Justice Selection Center http://www.gulfcoast.edu/north_bay/selection Our physical location: Criminal Justice Selection Center North Bay Campus, Abbott Building 5230

More information

EMPLOYMENT APPLICATION

EMPLOYMENT APPLICATION SPALDING COUNTY BOARD OF COMMISSIONERS 119 E. Solomon Street, P.O. Box 1087 Griffin, Georgia 30224 www.spaldingcounty.com EMPLOYMENT APPLICATION SPALDING COUNTY ONLY ACCEPTS APPLICATIONS FOR CURRENTLY

More information

MASSAGE THERAPIST LICENSE APPLICATION

MASSAGE THERAPIST LICENSE APPLICATION Licensing MASSAGE THERAPIST LICENSE APPLICATION A City of Forest Lake Massage Therapist License is required prior to performing massage services within the City of Forest Lake. Chapter 115 of the Forest

More information

South Carolina Department of Insurance Professional Bondsman / Runner / Surety Bondsman License Application

South Carolina Department of Insurance Professional Bondsman / Runner / Surety Bondsman License Application South Carolina Department of Insurance Professional Bondsman / Runner / Surety Bondsman License Application Staple a passport size full-face photograph of applicant here. Please check only one type of

More information

Floyd Healthcare Management, Inc. Notice of Privacy Practices

Floyd Healthcare Management, Inc. Notice of Privacy Practices Floyd Healthcare Management, Inc. Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW

More information

FLORIDA. General Information for Renewal

FLORIDA. General Information for Renewal FLORIDA Educator Certification DIISTRIICT RENEWAL APPLIICATIION General Information for Renewal Each district school board shall renew state-issued professional certificates for individuals who hold a

More information

INFORMATION FOR COMPLETING APPLICATION FOR A LOCUM TENENS LICENSE TO PRACTICE PHYSICAL THERAPY

INFORMATION FOR COMPLETING APPLICATION FOR A LOCUM TENENS LICENSE TO PRACTICE PHYSICAL THERAPY Mail To: P.O. Box 8935 Ship To: 1400 E. Washington Avenue Madison, WI 53708-8935 Madison, WI 53703 FAX #: (608) 261-7083 E-Mail: dsps@wisconsin.gov Phone #: (608) 266-2112 Website: http:dsps.wi.gov PHYSICAL

More information

INSTRUCTION SHEET PHARMACY TECHNICIAN

INSTRUCTION SHEET PHARMACY TECHNICIAN INSTRUCTION SHEET PHARMACY TECHNICIAN An applicant for registration as a pharmacy technician may assist a registered pharmacist in the practice of pharmacy for a period of up to 60 days prior to the issuance

More information

APPLICATION FOR EMPLOYMENT Please TYPE or print using BLACK or BLUE ink

APPLICATION FOR EMPLOYMENT Please TYPE or print using BLACK or BLUE ink Name: First Last 11878 Avenue of Industry San Diego, CA 92128 Telephone: (858) 675-4200 Fax: (858) 675-9241 APPLICATION FOR EMPLOYMENT Please TYPE or print using BLACK or BLUE ink Date Application Completed:

More information

FLORIDA DEPARTMENT OF HEALTH BOARD OF DENTISTRY NON-PROFIT CORPORATION PERMIT APPLICATION

FLORIDA DEPARTMENT OF HEALTH BOARD OF DENTISTRY NON-PROFIT CORPORATION PERMIT APPLICATION FLORIDA DEPARTMENT OF HEALTH BOARD OF DENTISTRY N-PROFIT CORPORATION PERMIT APPLICATION Applications will be accepted only if completed by an officer of the non-profit organization. Any questions not applicable

More information

OKLAHOMA INSURANCE DEPARTMENT 3625 NW 56 th Street, Suite 100, Oklahoma City, OK 73112-4511

OKLAHOMA INSURANCE DEPARTMENT 3625 NW 56 th Street, Suite 100, Oklahoma City, OK 73112-4511 PLEASE PRINT OR TYPE 1.LAST NAME 2. FIRST NAME 3. MIDDLE REVISED 08/19/2014 4. SOCIAL SECURITY # 5. DATE OF BIRTH 4. GENDER MALE FEMALE 5. RESIDENCE ADDRESS (PHYSICAL) 6. CITY 7. STATE 8. ZIP 9. COUNTY

More information

Project Transformation Oklahoma Application PERSONAL PROFILE

Project Transformation Oklahoma Application PERSONAL PROFILE PERSONAL PROFILE 1. NAME: LAST FIRST MIDDLE 2. AmeriCorps members must be a United States citizen, U.S. National or Lawful Permanent Resident. Are you a U.S. Citizen, national, or lawful permanent resident

More information

Operator and for Merchant Mariner's Document

Operator and for Merchant Mariner's Document Section I - Personal Data Page 1 (For CG Use Only) Application Received Name (Last, First, Middle) (Maiden Name if applicable) Social Security Number of Birth (Month, Day, Year) Place of Birth (City, State,

More information

Instructions For Clinical Nurse Specialist (CNS) Applicants

Instructions For Clinical Nurse Specialist (CNS) Applicants RETAIN FOR REFERENCE Instructions For Clinical Nurse Specialist (CNS) Applicants GENERAL INFORMATION: An applicant for Clinical Nurse Specialist certification must hold a current, unrestricted license

More information

Marriage & Family Arizona Adoption Laws

Marriage & Family Arizona Adoption Laws Overview Arizona statutes addressing adoption are in Title 8 of the Arizona Revised Statutes. Federal laws concerning Indian Children also apply to adoption and are contained in the Indian Child Welfare

More information

HOW TO FILE A PETITION TO EXPUNGE JUVENILE OFFENSES

HOW TO FILE A PETITION TO EXPUNGE JUVENILE OFFENSES HOW TO FILE A PETITION TO EXPUNGE JUVENILE OFFENSES Disclaimer Neither the staff in Court Administration nor the staff in any Court office will be able to give you legal advice or help you fill out/complete

More information

DEPARTMENT OF HEALTH. APPLICATION FOR LIMITED LICENSURE and Instructions

DEPARTMENT OF HEALTH. APPLICATION FOR LIMITED LICENSURE and Instructions DEPARTMENT OF HEALTH BOARD OF CLINICAL SOCIAL WORK, MARRIAGE AND FAMILY THERAPY AND MENTAL HEALTH COUNSELING APPLICATION FOR LIMITED LICENSURE and Instructions APPLICATION FOR LIMITED LICENSURE INSTRUCTIONS

More information

APPLICATION INFORMATION FOR REAL ESTATE SALES ASSOCIATES AND BROKERS

APPLICATION INFORMATION FOR REAL ESTATE SALES ASSOCIATES AND BROKERS APPLICATION INFORMATION FOR REAL ESTATE SALES ASSOCIATES AND BROKERS QUALIFICATIONS An applicant for licensure as a Sales Associate or Broker must be at least 18 years of age; hold a high school diploma

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 PHARMACY TECHNICIAN REGISTRATION APPLICATION AND INSTRUCTIONS October

More information

EMS Certifications Previously Held Or Currently Held In PA, Other States or US Territories:

EMS Certifications Previously Held Or Currently Held In PA, Other States or US Territories: ff pennsylvania - DEPARTMENT OF HEALTH Bureau of Erne Medical Services imilmmlmt+lbitm Emergency Medical Services Provider Certification Application Purpose for completing this form o Initial Certification

More information

Street City State ZIP. Mailing Address (if different from above): Street City State ZIP

Street City State ZIP. Mailing Address (if different from above): Street City State ZIP I am applying for a: new license renewed license CLEO certification State of Ohio Application for License to Carry a Concealed Handgun Type or Print in Ink SECTION II Name of Applicant: Issuing Agency

More information

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. UNIVERSITY OF SOUTHERN CALIFORNIA USC NETWORK MEDICAL PLAN, DELTA DENTAL PLAN, USC SENIOR CARE PLAN AND HEALTHCARE FLEXIBLE SPENDING ACCOUNT PLAN NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH

More information

MAKE CHECK PAYABLE TO: TREASURER, STATE OF MAINE FOR OFFICE USE ONLY STATE OF MAINE

MAKE CHECK PAYABLE TO: TREASURER, STATE OF MAINE FOR OFFICE USE ONLY STATE OF MAINE MAKE CHECK PAYABLE TO: TREASURER, STATE OF MAINE FOR OFFICE USE ONLY STATE OF MAINE CHECK # $35.00 $20.00 APPLICATION FOR PERMIT TO LICENSE # $2.00 CARRY CONCEALED FIREARMS (Resident) ISSUE DENIED DATE:

More information

POWER OF ATTORNEY., the parent(s), the undersigned, residing at, in the county of, state of, hereby appoint the child s

POWER OF ATTORNEY., the parent(s), the undersigned, residing at, in the county of, state of, hereby appoint the child s POWER OF ATTORNEY Case No. I/we,, the parent(s) of, the undersigned, residing at, in the county of, state of, hereby appoint the child s grandparent,, residing at, in the state of Ohio, with whom the child

More information