Additional Adult Application - Application For Approval Of Three Or Four Infants/toddlers - Office Of Child Care Maryland State Department Of Education

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MARYLAND STATE DEPARTMENT OF EDUCATION
Office of Child Care
ADDITIONAL ADULT APPLICATION
APPLICATION FOR APPROVAL OF THREE OR FOUR INFANTS/TODDLERS
1. Applying as an Additional Adult for:
Name of Registered Family Child Care Provider: __________________________________________
Address of Registered Home: _________________________________________ Apt. #: __________
City/Town: ____________________________ Zip Code: __________ Phone #: _________________
2. Name: ___________________________________________________________________________
Last
First
Middle
Maiden
If you have had any other names, please list them: _________________________________________
Female
Male
Social Security #: _______________________ Date of Birth: _____________
3. Home Address: ___________________________________________________ Apt. #: ___________
City/Town: ___________________________________ State: ___________ Zip Code: ___________
Phone #: ____________________________
E-mail address: _______________________________
Mailing Address (if different from home address): _________________________________________
_________________________________________________________________________________
4. If currently working, can you receive calls at work?
Yes
No
If Yes, give your work telephone number: _______________________________________________
5. Have you ever been convicted of any criminal charge, or are you awaiting trial on any criminal
charge?
Yes
No If Yes, explain: ______________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
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OCC 1275 – Revised 10/08 – All previous editions are obsolete.

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