Individual personnel information 



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MARYLAND STATE DEPARTMENT OF EDUCATION I am applying for: (check all that apply)

Office of Child Care  Aide  Assistant Teacher (school age)



INDIVIDUAL PERSONNEL INFORMATION  Teacher:  Infant/Toddler  Preschool  School age

 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; Maiden)
HOME ADDRESS:      

(Street; P.O. Box or Apt. #; City; County; State; Zip Code)
HOME PHONE:       WORK PHONE:      
BIRTHDATE:       (attach copy of Birth Certificate or Driver’s License) SOCIAL SECURITY #:      
Have you been evaluated to work in a child care center in the State of Maryland?  No  Yes (attach copy of evaluation)

Center name/location:      



EDUCATION:

1. Did you complete high school?  No  Yes (attach copy of diploma, equivalency certificate or transcript)

2. Did you complete any of the following? No  Yes (check all that apply) (attach copies of certificates/transcripts)

45 hour course:  Infant/Toddler  School age  School age Director

90 hour course:  Infant/Toddler  Preschool  School age

Other:  Child Development Associate Credential  Military Certificate

3. Did you attend college?  No  Yes, number of credits earned     (attach copy of transcript)

4. Did you earn a degree?  No  Yes, Year       Name of School      

Major:       Degree earned:       (attach copy of degree/transcript)

5. Do you have a teaching certificate or approval from the MD State Dept. of Education or another state?  No  Yes (attach copy of

certificate or approval letter)
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 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. Attach additional pages if necessary.



Dates Worked

From To


Mo Yr Mo Yr

Name of Facility

(start with present employer)

Address and Phone #


Supervisor


Position

Ages of Children


# of Hours Worked Per Week

  


    

  

    


     

     

     

     

     

   

  


    

  

    


     

     

     

     

     

   

  


    

  

    


     

     

     

     

     

   

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

Signature Date



OCC 1205 Revised 3/09 Fill-in.


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