Occ 1205 Form - Individual Personnel Information printable pdf download

MARYLAND STATE DEPARTMENT OF EDUCATION

I am applying for: (check all that apply)

Office of Child Care

___ Aide

___ Assistant Teacher (school age)

___Teacher: ___ Infant/Toddler ___ Preschool ___ School age

INDIVIDUAL PERSONNEL INFORMATION

___ Director: ___ Infant/Toddler ___ Preschool ___ School age

This form is to be completed by potential or new staff not previously evaluated or staff requesting re-evaluation. SEND THE

COMPLETED FORM AND ALL SUPPORTING DOCUMENTATION TO THE OFFICE OF CHILD CARE REGIONAL

OFFICE. THE EVALUATION WILL BE BASED SOLELY ON DOCUMENTATION SUBMITTED TO OCC.

NAME: ____________________________________________________________________________________________________________________

Last

First

Middle

OTHER NAMES USED

__________________________________________________________________________________________________________________________________________________________

HOME ADDRESS: __________________________________________________________________________________________________________

Street

P.O. Box or Apt. #

City

County

State

Zip Code

PREFERRED CONTACT NUMBER: (______)__________________ Email:____________________________________________________________

BIRTHDATE:

_______ ____________ (attach proof of birthdate)

SOCIAL SECURITY #: ______________________________________

Have you been evaluated to work in a child care center in the State of Maryland? If “Yes”, attach copy of evaluation and STOP HERE unless

requesting re-evaluation.

Requesting Re-evaluation

EDUCATION:

1. Did you complete high school?

No If “Yes”, attach copy of diploma, equivalency certificate or transcript.

2. Did you complete any of the following? If “Yes” check all that apply and attach copies of certificates/transcripts.

45 hour course:

Infant/Toddler

Preschool

School age

Director Administration Training

90 hour course:

Infant/Toddler

Preschool

School age

Other:

CDA Credential

Military Certificate

ADA

Breastfeeding Practices

9 hour Communication

3. Did you attend college?

No If “Yes”, number of credits earned ___________ Did you earn a degree?

Yes

Major ___________________________________Name of School __________________________________________ (attach copy of transcript)

4. Do you have a teaching certificate or teaching certification?

No If “Yes”, attach copy of certificate or approval letter.

5. Do you have Montessori Credentials?

No If “Yes” attach copy of credential(s).

EXPERIENCE:

Provide information about your supervised experience working with groups of children in licensed child care centers, public/private schools, as a

registered provider or other approved settings. Attach additional pages if necessary. Attach documentation from each employer, which states the

number of hours worked, the ages of the children worked with, the position and the length of time worked.

Dates Worked

# of Hours

From

Name of Facility

Address and Phone #

Supervisor

Position

Ages of

Worked

(start with present employer)

Children

Per Week

I confirm that the above information is true and correct to the best of my knowledge.

______________________________________________________________

___________________________________

Signature

Date

OCC 1205 - Revised 8/16 - All previous editions are obsolete.

Occ 1205 Form - Individual Personnel Information

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