Form Cc-200 - Certified Family Child Care Provider Application
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3ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Page 1 of 3
CC-200-FF (7-17)
Child Care Administration
CERTIFIED FAMILY CHILD CARE PROVIDER APPLICATION
Date Received:
Family Child Care Provider
In-Home Provider
APPLICANT INFORMATION
FULL LEGAL NAME
(Last, First, M.I.)
OTHER NAMES USED
(Maiden Name, other Married Names, Nicknames, etc.)
SOCIAL SECURITY NUMBER
DATE OF BIRTH
(mm/dd/yyyy)
PHONE NUMBER
EMAIL ADDRESS
(Best number to reach you)
(Required)
RESIDENTIAL ADDRESS
(No., Street)
CITY
STATE
ZIP CODE
MAILING ADDRESS
(If different from residential)
CITY
STATE
ZIP CODE
HOUSING INFORMATION:
Own
Rent*
*Obtain a completed Landlord Permission form (CCA-1175A) from property owner.
TYPE OF CURRENT RESIDENCE:
House
Apartment
Mobile home
Other (Specify)
Have you lived out of state in the last 5 years?
Yes
No
PREFERRED LANGUAGE:
English
Spanish
Other (Specify)
RACE
:
AI (American Indian or Alaskan Native)
AS (Asian)
(You may voluntarily indicate your race and ethnic background)
BL (Black or African-American)
NH (Native Hawaiian or other Pacific Islander)
WH (White)
ETHNICITY: Hispanic?
Yes
No
Are you a U.S. citizen?
Yes
No
If no, are you legally eligible to work in the U.S.?
Yes
No
(You will be required to provide documentation)
Are you an enrolled member of an American Indian tribe?
Yes
No
If yes, which tribe?
Are you currently employed?
Yes
No
If yes, what are the days and hours?
Are you currently a licensed foster parent?
Yes
No
If yes, how many children are you licensed for?
HOUSEHOLD MEMBERS
“Household Member” means a person who does not provide child care services who resides in the home facility
of a provider for 21 days or longer or who resides periodically throughout the year for a total of at least 21 days.
Household Member #1
I DO NOT have any household members
LAST NAME
FIRST NAME
MIDDLE NAME
OTHER NAMES USED
(Maiden Name, other Married Names, Nicknames, etc.)
SOCIAL SECURITY NUMBER
DATE OF BIRTH
(mm/dd/yyyy)
RELATIONSHIP TO YOU
Has this person lived out of state in the last 5 years?
Yes
No
Household Member #2
N/A
LAST NAME
FIRST NAME
MIDDLE NAME
OTHER NAMES USED
(Maiden Name, other Married Names, Nicknames, etc.)
SOCIAL SECURITY NUMBER
DATE OF BIRTH
(mm/dd/yyyy)
RELATIONSHIP TO YOU
Has this person lived out of state in the last 5 years?
Yes
No
See page 3 for EOE/ADA/LEP/GINA disclosures
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