Form CC-201-A "Registration & Employment History for Providing DES Certified Services" - Arizona

What Is Form CC-201-A?

This is a legal form that was released by the Arizona Department of Economic Security - a government authority operating within Arizona. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2011;
  • The latest edition provided by the Arizona Department of Economic Security;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CC-201-A by clicking the link below or browse more documents and templates provided by the Arizona Department of Economic Security.

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Download Form CC-201-A "Registration & Employment History for Providing DES Certified Services" - Arizona

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CC-201-A (11-11)
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Child Care Administration
Applicant
REGISTRATION AND EMPLOYMENT HISTORY FOR
Household Member
DATE
PROVIDING DES-CERTIFIED CHILD CARE SERVICES
Back-up
NAME OF PERSON BEING FINGERPRINTED (Last, First, M.I.)
SOC. SEC. NO.
OCCUPATION
CHILD CARE PROVIDER'S NAME (If different from above)
EMPLOYMENT HISTORY
Complete the following employment history. Start with your present or most recent job and go back five years. If necessary, use an additional sheet
and attach it to this form.
1. EMPLOYER'S NAME
JOB TITLE
EMPLOYMENT DATES
From:
To:
ADDRESS (No., Street, Suite No., City, State, ZIP)
PHONE NO. (With area code)
REASON FOR LEAVING
2. EMPLOYER'S NAME
JOB TITLE
EMPLOYMENT DATES
From:
To:
ADDRESS (No., Street, Suite No., City, State, ZIP)
PHONE NO. (With area code)
REASON FOR LEAVING
3. EMPLOYER'S NAME
JOB TITLE
EMPLOYMENT DATES
From:
To:
ADDRESS (No., Street, Suite No., City, State, ZIP)
PHONE NO. (With area code)
REASON FOR LEAVING
Yes No
I give my permission for the DES to contact the employers listed above. If no, give reason. ____________________________________
_____________________________________________________________________________________________________________
Have you ever been employed to work with children? If yes, list employer's name and address. _________________________________
_____________________________________________________________________________________________________________
To your knowledge, have you ever been the subject of a Child Protective Services investigation? If yes, explain. ___________________
_____________________________________________________________________________________________________________
Have you ever been fired or forced to resign from a job working with children? If yes, give reason. ______________________________
_____________________________________________________________________________________________________________
Have you ever been a DES-certified child care home provider? If yes, when and where. _______________________________________
_____________________________________________________________________________________________________________
HOUSEHOLD COMPOSITION (To be completed by certified provider/applicant only)
I understand that any person who is present in my home will be considered to be a resident if the person:
1. Is present in my home for 21 days or longer;
2. Uses the address of my home as a permanent address of record; and/or
3. Receives benefits or is listed as a member of my household for official documentation.
In addition, I understand that the above may not be the sole considerations.
I will notify my child care certification specialist whenever any individual 18 years of age or older, not listed below, moves into my residence
or begins to reside in my home, and whenever anyone who resides in my home turns 18 years of age.
The following person(s) 18 years of age or older reside in my home:
NAME (Last, First)
DOB
RELATIONSHIP
NAME (Last, First)
DOB
RELATIONSHIP
A CC-201, Certification Statement for Providing DES Child Care Services must also be completed and signed in the presence of a notary
public.
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with
Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic
Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities, or
employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. The Department must make a reasonable
accommodation to allow a person with a disability to take part in a program, service or activity. For example, this means if necessary, the Department
must provide sign language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the
Department will take any other reasonable action that allows you to take part in and understand a program or activity, including making reasonable
changes to an activity. If you believe that you will not be able to understand or take part in a program or activity because of your disability, please let
us know of your disability needs in advance if at all possible. To request this document in alternative format or for further information about this
policy, contact (602) 542-4248; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request.
CC-201-A (11-11)
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Child Care Administration
Applicant
REGISTRATION AND EMPLOYMENT HISTORY FOR
Household Member
DATE
PROVIDING DES-CERTIFIED CHILD CARE SERVICES
Back-up
NAME OF PERSON BEING FINGERPRINTED (Last, First, M.I.)
SOC. SEC. NO.
OCCUPATION
CHILD CARE PROVIDER'S NAME (If different from above)
EMPLOYMENT HISTORY
Complete the following employment history. Start with your present or most recent job and go back five years. If necessary, use an additional sheet
and attach it to this form.
1. EMPLOYER'S NAME
JOB TITLE
EMPLOYMENT DATES
From:
To:
ADDRESS (No., Street, Suite No., City, State, ZIP)
PHONE NO. (With area code)
REASON FOR LEAVING
2. EMPLOYER'S NAME
JOB TITLE
EMPLOYMENT DATES
From:
To:
ADDRESS (No., Street, Suite No., City, State, ZIP)
PHONE NO. (With area code)
REASON FOR LEAVING
3. EMPLOYER'S NAME
JOB TITLE
EMPLOYMENT DATES
From:
To:
ADDRESS (No., Street, Suite No., City, State, ZIP)
PHONE NO. (With area code)
REASON FOR LEAVING
Yes No
I give my permission for the DES to contact the employers listed above. If no, give reason. ____________________________________
_____________________________________________________________________________________________________________
Have you ever been employed to work with children? If yes, list employer's name and address. _________________________________
_____________________________________________________________________________________________________________
To your knowledge, have you ever been the subject of a Child Protective Services investigation? If yes, explain. ___________________
_____________________________________________________________________________________________________________
Have you ever been fired or forced to resign from a job working with children? If yes, give reason. ______________________________
_____________________________________________________________________________________________________________
Have you ever been a DES-certified child care home provider? If yes, when and where. _______________________________________
_____________________________________________________________________________________________________________
HOUSEHOLD COMPOSITION (To be completed by certified provider/applicant only)
I understand that any person who is present in my home will be considered to be a resident if the person:
1. Is present in my home for 21 days or longer;
2. Uses the address of my home as a permanent address of record; and/or
3. Receives benefits or is listed as a member of my household for official documentation.
In addition, I understand that the above may not be the sole considerations.
I will notify my child care certification specialist whenever any individual 18 years of age or older, not listed below, moves into my residence
or begins to reside in my home, and whenever anyone who resides in my home turns 18 years of age.
The following person(s) 18 years of age or older reside in my home:
NAME (Last, First)
DOB
RELATIONSHIP
NAME (Last, First)
DOB
RELATIONSHIP
A CC-201, Certification Statement for Providing DES Child Care Services must also be completed and signed in the presence of a notary
public.
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with
Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic
Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities, or
employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. The Department must make a reasonable
accommodation to allow a person with a disability to take part in a program, service or activity. For example, this means if necessary, the Department
must provide sign language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the
Department will take any other reasonable action that allows you to take part in and understand a program or activity, including making reasonable
changes to an activity. If you believe that you will not be able to understand or take part in a program or activity because of your disability, please let
us know of your disability needs in advance if at all possible. To request this document in alternative format or for further information about this
policy, contact (602) 542-4248; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request.
CC-201-A (11-11) - REVERSE
DEPARTAMENTO DE SEGURIDAD ECONÓMICA DE ARIZONA
Administración de Cuidado para Niños
Solicitante
HISTORIA DE REGISTRO Y EMPLEO PARA PROVEER
Miembro del hogar
FECHA
CUIDADO CERTIFICADO POR DES PARA NIÑOS
Substituto
Nombre de persona quien tomarse las huellas digitales (Apellido, nombre, inicial)
Núm. de Seg. Soc.
Ocupación
Nombre del proveedor(a) de cuidado para niños (Si es diferente al de arriba)
HISTORIA DE EMPLEO
Llene el historial de empleo a continuación. Empiece con su trabajo actual o más reciente, y retroceda cinco años. Si necesita, use otra hoja e
inclúyala con este formulario.
1. Nombre del empleador
Título del puesto
Fechas de empleo
Desde:
Hasta:
Domicilio (Núm., calle, núm. oficina, ciudad, estado, ZIP)
Teléfono
Razón de dejar el empleo
2. Nombre del empleador
Título del puesto
Fechas de empleo
Desde:
Hasta:
Domicilio (Núm., calle, núm. oficina, ciudad, estado, ZIP)
Teléfono
Razón de dejar el empleo
3. Nombre del empleador
Título del puesto
Fechas de empleo
Desde:
Hasta:
Domicilio (Núm., calle, núm. oficina, ciudad, estado, ZIP)
Teléfono
Razón de dejar el empleo
No
Autorizo al DES a comunicarse con los empleadores mencionados arriba. Si no, dé la razón. ___________________________________
_____________________________________________________________________________________________________________
¿Alguna vez ha trabajado con niños? Si sí, escriba el nombre y el domicilio del empleador. ____________________________________
_____________________________________________________________________________________________________________
Que sepa Ud., ¿alguna vez Servicios Protectores para Niños le ha investigado? Si sí, explique. _________________________________
_____________________________________________________________________________________________________________
¿Alguna vez le han despedido u obligado a renunciar de un trabajo con niños? Si sí, dé la razón. ________________________________
_____________________________________________________________________________________________________________
¿Alguna vez DES le ha certificado para cuidar niños en su casa? Si sí ¿cuándo y dónde? ______________________________________
_____________________________________________________________________________________________________________
COMPOSICION DEL HOGAR (Sólo para uso de proveedor / solicitante certificado)
Entiendo que toda persona quien esté en mi hogar será considerada residente si la persona:
1. Está presente en mi hogar por 21 días o más;
2. Usa mi domicilio como su domicilio oficial permanente; y/o
3. Recibe beneficios o es mencionada como miembro de mi hogar en documentos oficiales.
Además, enteindo que las consideraciones no necesariamente se limitarán a lo mencionado arriba.
Notificaré a mi especialista de certificación para cuidado de niños cada vez que alguien de 18 o más años, no mencionado a continuación,
se mude a mi residencia o comience a residir en mi hogar, y cada vez que algún residente de mi hogar cumpla 18 años.
La siguiente persona(s) de 18 o más años reside(n) en mi hogar:
NOMBRE (Apellido, nombre)
F.D.N.
RELACION
NOMBRE (Apellido, nombre)
F.D.N.
RELACION
También deberá llenarse y firmarse ante un notario público el formulario CC-201, Declaración de certificación para proveer servicios de
cuidado para niños.
Programa y Empleador con Igualdad de Oportunidades • Bajo los Títulos VI y VII de la Ley de los Derechos Civiles de 1964 (Títulos VI y VII) y la Ley de
Estadounidenses con Discapacidades de 1990 (ADA por sus siglas en inglés), Sección 504 de la Ley de Rehabilitación de 1973, Ley contra la Discriminación
por Edad de 1975 y el Título II de la Ley contra la Discriminación por Información Genética (GINA por sus siglas en inglés) de 2008; el Departamento
prohíbe la discriminación en la admisión, programas, servicios, actividades o empleo basado en raza, color, religión, sexo, origen, edad, discapacidad,
genética y represalias. El Departamento tiene que hacer las adaptaciones razonables para permitir que una persona con una discapacidad participe en un
programa, servicio o actividad. Esto significa por ejemplo que, si es necesario, el Departamento tiene que proporcionar intérpretes de lenguaje de señas para
personas sordas, un establecimiento con acceso para sillas de ruedas o material con letras grandes. También significa que el Departamento tomará cualquier
otra medida razonable que le permita a usted entender y participar en un programa o en una actividad, incluso efectuar cambios razonables en la actividad. Si
usted cree que su discapacidad le impedirá entender o participar en un programa o actividad, por favor infórmenos lo antes posible de lo que usted necesita
para acomodar su discapacidad. Para obtener este documento en otro formato u obtener información adicional sobre esta política, llame al 602-542-4248;
Servicios de TTY/TDD: 7-1-1. • Ayuda gratuita con traducciones relacionadas a los servicios del DES está disponible a solicitud del cliente..
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