Employment Application
Transcripción
Employment Application
Employment Application 1. Zero Tolerance 2. CPR/ First Aid 3. HIV/AIDS-Infection Control 4. Core Competencies-Intro to Developmental Disabilities 5. Core Competencies- Health & Safety 6. Core Assurances- Choices and Rights of Individuals 7. HIPPA (online) 8. Florida Administrative Code 65G-8 9. Overview Medication Administrative 65G-7 10. Development and Implementation of the Required Documentation of each Waiver Service 11. Person Centered and Implementation Plan for Providers 12. Medicaid Waiver Services Agreement and its Attachments as well as Coverage and Limitations Handbook and its Appendices 13. Social Security Card 14. FDLE 15. Local Law 16. APD Good Moral Affidavit 17. 2 Letters of Reference 18. Resume/ High School Diploma 19. Car Insurance 20. Car Registration 21. Florida ID 22. Light of Life Application 23. W-9 Light of Life, Inc – 1801 Sandy Creek Lane Suite 102 Orlando Fl 32826 Office: 407-568-8704 Fax: 407-674-6808 Lightoflifeinc.com Email: [email protected] AN EQUAL OPPORTUNITY EMPLOYER A DRUG –FREE WORKPLACE “Encendiendo el mundo una vida a la Vez” APPLICATION FOR EMPLOYMENT APPLICANT MAY BE CHECKED FOR CRIMINAL BACKGROUND Nombre: (apellido primero) Fecha de hoy Seguro Social Fecha de nacimento Dirección Ciudad Estado y Código Postal Dirección anterior Ciudad Estado y Código Postal E-Mail: Está usted 18 años o más Si □ No □ Telefono: ( ) _____ ______________ Está usted un U.S. Ciudadano o un extranjero autorizado a trabajar Celular: ( En el caso de la emergencia ) ____ __________________ en el U.S.A Dirección: Si □ No □ Teléfono: H( ) ____ ______________ W( ) ____ ______________ C ( ) _____ _____________ EMPLEO Empleo/posición pasados: Fecha del comienzo/ del extremo: Nombre del supervisor o del director pasado: ¿Razón de irse? Usted ha trabajado siempre para esta agencia antes? Si ¿Quién le refirió a esta agencia? □ No □ □ Agencia del empleado □ Publicidad del periódico □ Amigo □ ¿Cuándo? □ Sin-Llamar (walk-In) □ Otro □ LE SIEMPRE HAN CONDENADO POR UN CRIMEN? Si No Si sí, explique el número de convicciones, naturaleza de las ofensas que conducen a las convicciones, si estaba recientemente, oraciones impuesto, y tipos de rehabilitación.__________________________________________________. EDUCACION NOMBRE DE LA ESCUELA TIPO DE ESCUELA LOCALIZACIÓN (Dirección completa del correo) NÚMERO DE LOS AÑOS TERMINADO Necesario High School secundaria Universidad Escuela Comercial (Bus./Trade school) GENERAL Conocimiento de el ingles: Hablo el □ Leo el □ Escribo el □ Conocimiento de el espanol: Hablo el □ Leo el □ Escribo el □ Habilidades/Entrenamientos especiales 1801 Sandy Creek Lane, Suite 102 Orlando, Fl 32826 Phone: 407-568-8704 Fax: 407-674-6808 PRINCIPAL & GRADO AN EQUAL OPPORTUNITY EMPLOYER A DRUG –FREE WORKPLACE “Lighting the World One Life at a Time” APPLICATION FOR EMPLOYMENT APPLICANT MAY BE CHECKED FOR CRIMINAL BACKGROUND Name: (Last Name First) Today's Date Social Security DOB Present Address City State Code and Zip Previous Address City State Code and Zip E-Mail: Are you 18 years or older □ Phone: ( ) ______ _______________ □ Yes No In case of Emergency Are you a U.S. Citizen or an Alien authorized to work Cell: ( ) ____ __________________ Address in the U.S.A. □ □ Yes No Phones: H( ) ______________ W( ) ______________ C( ) ______________ EMPLOYMENT Last Employment/Position: Start/End Date: Name of last supervisor or Director: Reason for leaving? Have you ever worked for this agency before? Who referred you to this agency? □ Employee Agency Yes □ □ Newspaper Advertising No □ When? □ Friend □ □ Walk-In □ Other □ HAVE YOU EVER BEEN CONVICTED OF A CRIME? Yes No If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation. _________________________________________________ EDUCATION TYPE OF SCHOOL NAME OF SCHOOL LOCATION (Complete mailing address) NUMBER OF YRS COMPLETED Needed High School College Bus. or Trade School GENERAL English Language Knowledge: Speaks □ Read □ Write □ Spanish Language Knowledge: Speaks □ Read □ Write □ Special Trainings/Skills 1801 Sandy Creek Lane, Suite 102 Orlando, Fl 32826 Phone: 407-568-8704 Fax: 407-674-6808 MAJOR & DEGREE Substitute Form W-9 (Rev. March 2002) Request for Taxpayer Identification Number and Certification Give form to the requester. Do not send to the IRS. Please print or type Name (See Specific Instructions on page 2.) Business name, if different from above. (See Specific Instructions on page 2.) Check appropriate box: Individual/Sole Proprietor Corporation Partnership LLC filing as Sole Proprietor LLC filing as Corporation LLC filing as Partnership Address (number, street, and apt. or suite no.) Other Requestor’s name and address (optional) City, state, and ZIP code Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 2. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 2. Note: If the account is in more than one name, see the chart on page 2 for guidelines on whose number to enter. List account number(s) here (optional) Social security number or Part II Employer identification number For U.S. Payees Exempt From Backup Withholding (See the instructions on page 2.) Part III Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. I am a U.S. person (including a U.S. resident alien). Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on you tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must provide your correct TIN. (See the instructions on page 2) Sign Here Signature of U.S. person What is backup withholding? Persons making certain payments to you must withhold A person who is required to file an information and pay to the IRS 31% of such payments under certain conditions. This is called “backup return with the IRS must get your correct withholding.” Payments that may be subject to taxpayer identification number (TIN) to report, backup withholding include interest, dividends, for example, income paid to you, real estate broker and barter exchange transactions, transactions, mortgage interest you paid, rents, royalties, non-employee pay, and certain acquisition or abandonment of secured property, cancellation of debt, or contributions payments from fishing boat operators. Real estate transactions are not subject to backup you made to an IRA. withholding. Use Form W-9 only if you are a U.S. person (including a resident alien), to give your correct If you give the requester your correct TIN, TIN to the person requesting it (the requester) make the proper certifications, and report all your taxable interest and dividends on your tax and, when applicable, to: return, payments you receive will not be 1. Certify the TIN you are giving is correct (or subject to backup withholding. Payments you you are waiting for a number to be issued), receive will be subject to backup withholding if: 2. Certify you are not subject to backup withholding, or 1. You do not furnish your TIN to the 3. Claim exemption from backup withholding requester, or if you are a U.S. exempt payee. 2. You do not certify your TIN when required (see the Part III instructions on page 2 for If you are a foreign person, use the details), or appropriate Form W-8. See Pub. 515, Withholding of Tax on Nonresident Aliens and 3. The IRS tells the requester that you Foreign Corporations. furnished an incorrect TIN, or Note: If a requester gives you a form other 4. The IRS tells you that you are subject to than Form W-9 to request your TIN, you must backup withholding because you did not report use the requester’s form if it is substantially all your interest and dividends on your tax similar to this Form W-9. return (for reportable interest and dividends only), or Purpose of Form Date 5. You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only). Certain payees and payments are exempt from backup withholding. See the Part II instructions and the separate Instructions for the Requester of Form W-9. Penalties Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect. Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty. Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment. Misuse of TINs. If the requester discloses or uses TINs in violation of Federal law, the requester may be subject to civil and criminal penalties. Substitute Form W-9 (Rev. 03-2002) Substitute Form W-9 (Rev. 03-2002) Specific Instructions Name. If you are an individual, you must generally enter the name shown on your social security card. However, if you have changed your last name, for instance, due to marriage without informing the Social Security Administration of the name change, enter your first name, the last name shown on your social security card, and your new last name. If the account is in joint names, list first and then circle the name of the person or entity whose number you enter in Part I of the form. Sole proprietor. Enter your individual name as shown on your social security card on the “Name” line. You may enter your business, trade, or “doing business as (DBA)” name on the “Business name” line. Limited liability company (LLC). If you are a single-member LLC (including a foreign LLC with a domestic owner) that is disregarded as an entity separate from its owner under Treasury regulations section 301.7701-3, enter the owner’s name on the “Name” line. Enter the LLC’s name on the “Business name” line. Caution: A disregarded domestic entity that has a foreign owner must use the appropriate Form W-8. Other entities. Enter your business name as shown on required Federal tax documents on the “Name” line. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on the “Business name” line. Page 2 the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA or MSA. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return. The IRS may also Part II—For U.S. Payees Exempt From provide this information to the Department of Justice Backup Withholding for civil and criminal litigation, and to cities, states, Individuals (including sole proprietors) are not and the District of Columbia to carry out their tax exempt from backup withholding. Corporations laws. are exempt from backup withholding for You must provide your TIM whether or not you are certain payments, such as interest and required to file a tax return. Payers must generally dividends. For more information on exempt withhold 31% of taxable interest, dividend, and payees, see the separate Instructions for the certain other payments to a payee who does not Requester of Form W-9. give a TIN to a payer. Certain penalties may also apply. If you are exempt from backup withholding, you should still complete this form to avoid possible erroneous backup withholding. Enter What Name and Number To your correct TIN in Part I, write “Exempt” in Give the Requestor Part II, and sign and date the form. If you are a nonresident alien or a foreign For this type of account: Give name and SSN of: entity not subject to backup withholding, give the requester the appropriate completed Form W-8. 1. Individual The individual backup withholding on all such payments until you provide your TIN to the requester. Note: Writing “Applied For” means that you have already applied for a TIN or that you intend to apply for one soon. Part III—Certification 2. Two or more individuals (joint account) The actual owner of the account or, if combined funds, the first individual on the account 1 The Minor 2 To establish to the withholding agent that you are a U.S. person, or resident alien, sign Form 3. Custodian account of a minor (Uniform Gift to W-9. You may be requested to sign by the Minors Act) withholding agent even if items 1, 3, and 5 4. a. The usual revocable The grantor-trustee 1 below indicate otherwise. savings trust (grantor is also For a joint account, only the person whose trustee) TIN is shown in Part I should sign (when b. So-called trust The actual owner 1 required). account that is not a Part I—Taxpayer Identification Number (TIN) legal or valid trust 1. Interest, dividend, and barter exchange under state law accounts opened before 1984 and broker Enter your TIN in the appropriate box. 5. Sole proprietorship The owner 3 accounts considered active during 1983. If you are a resident alien and you do not You must give your correct TIN, but you do not For this type of account: Give name and EIN of: have and are not eligible to get an SSN, your have to sign the certification. TIN is your IRS individual taxpayer identification 6. Sole Proprietorship The owner 3 2. Interest, dividend, broker, and barter number (ITIN). Enter it in the social security Legal entity 4 exchange accounts opened after 1983 and 7. A valid trust, estate, or number box. If you do not have an ITIN, see pension trust broker accounts considered inactive 8. Corporate The corporation How to get a TIN below. during 1983. You must sign the certification or 9. Association, club, The organization If you are a sole proprietor and you have an backup withholding will apply. If you are religious, charitable, EIN, you may enter either your SSN or EIN. subject to backup withholding and you are educational, or other However, the IRS prefers that you use your tax-exempt merely providing your correct TIN to the organization SSN. requester, you must cross out item 2 in the 10. Partnership The partnership certification before signing the form. If you are an LLC that is disregarded as an 11. A broker or registered The broker or nominee entity separate from its owner (see Limited 3. Real estate transactions. You must sign nominee liability company (LLC) above), and are 12. Account with the The public entity the certification. You may cross out item 2 of Department of owned by an individual, enter your SSN (or the certification. Agriculture in the name “pre-LLC” EIN, if desired). If the owner of a 4. Other payments. You must give your of a public entity (such disregarded LLC is a corporation, partnership, as a state or local correct TIN, but you do not have to sign the etc., enter the owner’s EIN. government, school certification unless you have been notified that district, or prison) that Note: See the chart on this page for further you have previously given an incorrect TIN. receives agricultural clarification of name and TIN combinations. “Other payments” include payments made in program payments the course of the requester’s trade or business How to get a TIN. If you do not have a TIN, for rents, royalties, goods (other than bills for 1 apply for one immediately. To apply for an List first and circle the name of the person whose number merchandise), medical and health care SSN, get Form SS-5, Application for a Social you furnish. If only one person on a joint account has an services (including payments to corporations), SSN, that person’s number must be furnished. Security Card, from your local Social Security payments to a non-employee for services, 2 Administration office. Get Form W-7, Circle the minor’s name and furnish the minor’s SSN. payments to certain fishing boat crew Application for IRS Individual Taxpayer 3 You must show your individual name, but you may also members and fishermen, and gross proceeds Identification Number, to apply for an ITIN or enter your business or “DBA” name. You may use either paid to attorneys (including payments to Form SS-4, Application for Employer your SSN or your EIN (if you have one). Identification Number, to apply for an EIN. You corporations). 4 List first and circle the name of the legal trust, estate, or can get Forms W-7 and SS-4 from the IRS by 5. Mortgage interest paid by you, pension trust. (Do not furnish the TIN of the personal calling 1-800-TAX-FORM (1-800-829-3676) or acquisition or abandonment of secured representative or trustee unless the legal entity itself is not from the IRS’s Internet Web Site at property, cancellation of debt, qualified designated in the account title.) www.irs.gov. state tuition program payments, IRA or Note: If no name is circled when more than MSA contributions or distributions, and If you do not have a TIN, write “Applied For” one name is listed, the number will be in the space for the TIN, sign and date the form, pension distributions. You must give your considered to be that of the first name listed. correct TIN, but you do not have to sign the and give it to the requester. For interest and certification. dividend payments, and certain payments made with respect to readily tradable Privacy Act Notice instruments, generally you will have 60 days to get a TIN and give it to the requester before Section 6109 of the Internal Revenue Code you are subject to backup withholding on requires you to give your correct TIN to payments. The 60-day rule does not apply to other types of payments. You will be subject to persons who must file information returns with EMPLOYMENT REFERENCE (Name of Applicant/ Nombre del Candidato) ________________________________ has applied to become a Medicaid Waiver Provider. With your cooperation, completing this reference would greatly assist Light of Life, Inc in determining if the applicant’s qualifications meet the set criteria. We greatly appreciate your time and effort in this matter. Did you supervise the Applicant? Usted a supervisado este candidato? Y N If not what is your relationship with the applicant? Si no, cual es su relación con el candidato? __________________________________________________________________________ Date of Employment (Fechas de empleo) :_______________to ________________ Title when employed (titulo cuando comenzo el empleo): _________________________________________________ Name of Company (Nombre de la Compania): _________________________________________________________ Duties (obligaciones): ______________________________________________________________________________ Would you hire or rehire this person? Quieres contratar o recontratar a esta persona? __________________________________________________________________ If this is a personal reference, rate the applicant’s qualities? Responsibility (Responsabilidad) 1 2 3 Efficiency (Eficiencia) 3 4 5 Determination (Determinacion) 1 2 Organization (Organizacion) 2 3 1 2 1 Time Management (Manejo de Tiempo) 4 5 3 4 5 4 5 1 2 3 4 5 November 28, 2011 To all employees: The agency would like to share with all our Independent Contractor, the result and information we gather with the office of Unemployment. Unfortunately we are not liable for Florida Unemployment Compensation taxes. As a result, you will be denied for Unemployment since you have been determined by the Department of revenue Analyst an Independent Contractor. In the case that you insist in applying for this benefit in the future, you need to consider this letter as proof of ineligibility and bring it to the Unemployment office as proof. La agencia le gustaria compartir con todo nuestro trabajadores Independiente el resultado y la información que recibimos de la oficina de Desempleo. Desafortunadamente nosotros no somos legalmente responsables por los taxes de la compensación del Desempleo en Florida. Como resultado, ustedes serán negados por este beneficio, ya que todos los que trabajan para nuestra agencia han sido determinados por el Analista del Departamento de Revenue, Trabajadores Independientes. En caso que ustedes insistan en aplicar por este beneficio en el futuro, ustedes necesitan considerar esta carta como prueba de que no son elegibles, y llevarla a la oficina de Desempleo como prueba. Sincerely, Gisela Ramos President /Founder 1801 Sandy Creek Lane, Suite 102 Orlando, Fl 32826 Phone: 407-568-8704 Fax: 407-674-6808 Mandatory Trainings November 28, 2011 Dear Current or Future Employees, Light of Life, Inc. requires you to get and update these trainings as a requirement by our company as well as APD. It’s the employee’s responsibility to be aware and keep track of which classes you’re missing or need to update. Remember that Zero Tolerance is mandatory and must be updated every 3 years and CPR needs to be renewed every 1-3 years. You are able to go via internet at www.apd.myflorida.com to take some of the trainings required. Please note that it cost $15 to take online. Directions: Go to Provider and look for Provider Training, then Training options and click on APD area office. You will find a Map of Florida and click on the number 7. Once you go to Area training Information, click on Online Training Registration. The area 7 office where you can take the courses is at 400 West Robinson Street, Suite S430 Orlando, Fl 32801. You may contact them at (407)245-0440. o o o o o o o o o o o o o 1. Zero Tolerance 2. CPR and First Aid 3. HIV/AIDS-Infection Control 4. Core Competencies-Intro to Developmental Disabilities and Health & Safety 5. Medication Administration 6. Core Assurances- Choices and Rights of Individuals 7. HIPPA (online at http://www.dcf.state.fl.us/admin/training.shtml) -click on HIPAA Information and Action 8. Florida Administrative Code 65G-8 9. Overview Medication Administrative 65G-7 10. Medicaid Waiver Services Agreement and its Attachment as well as Coverage and Limitations Handbook and its Appendices. 11. Development & Implementation of the Required Documentation of each Waiver Service 12. Use of a Person-Centered Approach to Service Delivery 13. Reactive Strategies Procedures Sincerely, Gisela Ramos President /Founder 1801 Sandy Creek Lane, Suite 102 Orlando, Fl 32826 Phone: 407-568-8704 Fax: 407-674-6808 Entrenamientos obligatorios De noviembre el 28 de 2011 Estimados empleados actuales o futuros, Light of Life, Inc. requiere coger estos entrenamientos como partes de nuestras polizas y las de APD. Es responsabilidad del empleado tomar estos cursos y tener al dia las clases. Los cursos como Zero Tolerance, Core Compentencies y Health and Safety pueden ir al internet a ww.apd.myflorida.com y tomar estas clases. El costo de estas son 15 dolares por clase. También las pueden coger en APD y se pueden matricular por el internet al mismo website. La clase de Zero Tolerance es obligatoria y tiene que ser renovada cada tres años y el CPR cada dos años. Usted puede ir vía Internet a www.apd.myflorida.com a tomar algunos de los entrenamientos requeridos. Direcciones: Vaya al Provider y busque el Provider Training, busca Training options and y chasque encendido a la APD Area Office. Usted encontrará un mapa de la Florida y chascará encendido el número 7. Una vez que usted vaya a Area training Information, chasqu e encendido el Online Training Registration. La dirección donde se ofrecen los cursos: 400 West Robinson Street, Suite S430 Orlando, Fl 32801. Telefono: (407) 245-0440. Si tienen alguna pregunta puede llamar a la oficina. Los cursos requeridos por Light of Life, Inc. y APD son las siguientes: o o o o o o o o o o o o o 1. Zero Tolerance 2. CPR and First Aid 3. HIV/AIDS-Infection Control 4. Core Competencies-Intro to Developmental Disabilities and Health & Safety 5. Medication Administration 6. Core Assurances- Choices and Rights of Individuals 7. HIPPA (por internet: http://www.dcf.state.fl.us/admin/training.shtml) - chasque encendido HIPAA Information and Action 8. Florida Administrative Code 65G-8 9. Overview Medication Administrative 65G-7 10. Medicaid Waiver Services Agreement and its Attachment as well as Coverage and Limitations Handbook and its Appendices 11. Development & Implementation of the Required Documentation of each Waiver Service 12. Use of a Person-Centered Approach to Service Delivery 13.Reactive Strategies Procedures Sinceramente, Gisela Ramos Presidente /Founder 1801 Sandy Creek Lane, Suite 102 Orlando, Fl 32826 Phone: 407-568-8704 Fax: 407-674-6808 Request for Local Law Enforcement Check December 9, 2011 Dear prospective employees, You will be receiving a package from the agency in reference to your employment. You will find your Request for Local Enforcement Check Form, which will allow you to get your local background check. Please bring it to your nearest Sheriff Department’s Office or mail it to the address that appears on your form. You will be charged $5.00 dollars for Orange County per last name. Now, for the Osceola area it cost $5.00 dollars and for Brevard, it’s $5.00 per last name. The one for Seminole County is free of charge. If you are mailing the form, don’t forget to submit a money order for the appropriate amount where you are requesting the background check. If you have any questions regarding this matter, you may call the office at the number shown below. Este memo es en referencia a su paquete que esté recibiendo de empleo. En su paquete, encontrara la hoja que requerimos que use para buscar sus antecedentes criminales en su área local. Por favor traiga su formulario al el Departamento del Sheriff más cercano a usted o enviarla por correo a la dirección que aparece en su hoja. Usted pagara por el condado de Orange $5.00, Osceola $5.00 y Brevard $5.00 por cada nombre. En adición, el área de Seminole es gratis. Si usted está enviándolo por correo, por favor no se olvide de someter un Money orden con la cantidad apropiada donde usted está requiriendo su record criminal. Si usted tiene alguna pregunta al respecto, usted puede llamar la oficina al número que aparece debajo de la hoja. Sincerely, Gisela Ramos President /Founder 1801 Sandy Creek Lane, Suite 102 Orlando, Fl 32826 Phone: 407-568-8704 Fax: 407-674-6808 Request For Local Law Enforcement Check Orange County To: Orange County Sheriff’s Office P.O Box 1440 Orlando, Florida 32808-1440 Pursuant to Chapter 435, Laws of Florida, we request a local records check on the applicant listed below: First Name: _____________________________________ Middle Name: ___________________________________ Last Name: ______________________________________ Date of Birth: ____________________________________ Race/Sex: _______________________________________ Please document the finding and return the information to: 1801 Sandy Creek Lane, Suite 102 Orlando, FL 32826 Requested by: Gisela Ramos Agency of Health Care Administration Request For Local Law Enforcement Check Osceola County To: Osceola County Sheriff’s Office 2601 E. Irlo Bronson Memorial Hwy Kissimmee, Florida 34744-4494 Pursuant to Chapter 435, Laws of Florida, we request a local records check on the applicant listed below: First Name: _____________________________________ Middle Name: ___________________________________ Last Name: ______________________________________ Date of Birth: ____________________________________ Social Security: __________________________________ Race/Sex: _______________________________________ Please document the finding and return the information to: 1801 Sandy Creek Lane, Suite 102 Orlando, FL 32826 Requested by: Gisela Ramos Agency of Health Care Administration Request For Local Law Enforcement Check Seminole County To: Seminole County Sheriff’s Office 100 Bush Boulevard Sanford, Florida 32773-6706 Pursuant to Chapter 435, Laws of Florida, we request a local records check on the applicant listed below: First Name: _____________________________________ Middle Name: ___________________________________ Last Name: ______________________________________ Date of Birth: ____________________________________ Social Security: __________________________________ Race/Sex: _______________________________________ Please document the finding and return the information to: 1801 Sandy Creek Lane, Suite 102 Orlando, FL 32826 Requested by: Gisela Ramos Agency of Health Care Administration State of Florida Department of Children and Families Rick Scott Governor David E. Wilkins Secretary Live Scan Background Screening Submission Form Employers/Providers: Contact your local DCF Background Screening Office for ORI and Live Scan OCA numbers. The following information must be presented prior to or at the time of screening: 1. A valid picture ID FL921811Z 2. DCF Agency Identifier (ORI)# FL92----Z This is a nine digit number beginning with FL92 and ending with the letter “Z”. 0748-1242Z 3. DCF Live Scan OCA # --------Z This is a nine digit number beginning with your 2 digit Circuit Number, your OCA, and ending with the letter “Z”. Live Scan Vendors: Background Screening for the Department of Children and Families must include the following: A valid ORI entered into the Controlling Agency Identifier field (this may also be the Requesting Agency field) on the Transaction Screen, and The Provider Live Scan OCA number entered into the Originating Case Agency Field on the Miscellaneous Screen. Applicants Present this form to any Live Scan Vendor approved to submit Level 2 Background Screenings through the Florida Department of Law Enforcement. Live Scan vendors may be found on the Department of Children and Families website, at www.dcfbackgroundscreening.com, or the Florida Department of Law Enforcement website, at www.fdle.state.fl.us. 1317 Winewood Boulevard, Tallahassee, Florida 32399-0700 Mission: Protect the Vulnerable, Promote Strong and Economically Self-Sufficient Families, and Advance Personal and Family Recovery and Resiliency FDLE LIVE SCAN VENDORS BY COUNTY ORANGE COUNTY Orange - 1 Sure Scan 1516 Colonial Drive Ste 301 Orlando, FL, 32803 Hours : Mon-Thur 8am-6pm Fri 8am-4pm Tel : (407) 492-8270 Apt : Call for an appointment Cost $: 47.20 Orange - 1st Choice Live Scan Fingerprinting 989 Kennedy Blvd. Suite 204 Orlando, FL, 32810 Hours : Please call for an appointment Tel : (407) 476-SCAN (7226) Apt : Cost $: Orange - 3 G Fingerprinting LLC 15310 Amberly Drive Suite 250-Office 29 Tampa, FL, 33647 Hours : M-F 9am-5pm Tel : (813) 514-2930 Apt : Call for an appointment Cost $: 47.25 Orange - AAA Fingerprinting of Central Florida 5764 N. Orange Blossom Trail Orlando, FL, 32810 Hours : 9am-5:30pm weekdays, no appoint. necessary. After hours and weekends by appoint. Tel : (407) 299-7328 Apt : No appointment necessary unless after hours or weekend Cost $: 43.00 Orange - Clear Choice Electronic Fingerprinting, Live Scan and Notary Services 934 N. Magnolia Ave Orlando, FL, 32803 Hours : M-F 9am-4pm Tel : (407) 481-9826 Apt : Call for an appointment Cost $: 65.00 Orange - Daon Trusted Identity Services at The UPS Store 7512 Doctor Phillips Blvd, Ste 50 Orlando, FL, 32819 Hours: M-F 9am-7pm Sat. 9am-3pm Tel: (703) 797-2562 Apt: Appointment Required Cost $: 38.25 Orange - Daon Trusted Identity Services at The UPS Store 1969 S Alafaya Trail Orlando, FL, 32828 Hours : M-F 8:30am-7pm Sat 10:30am-3:30pm Tel : (703) 797-2562 Apt : Appointment Required Cost $: 38.25 Orange - L-1 Enrollment Services 509 S Chickasaw Trail Orlando, FL, 32825 Hours : M-F 9am-5pm Sat. 10am-2pm Tel : (800) 528-1358 Apt : Appointment required Cost $: 38.20 Orange - L-1 Enrollment Services 13750 W Colonial Dr Winter Garden, FL, 34787 Hours : M-F 1030am-615pm Tel : (800) 528-1358 Apt : Appointment required Cost $: 38.20 Orange - L-1 Enrollment Services 7512 Dr. Phillips Blvd Ste 50 Orlando, FL, 32819 Hours : M-F 10am-5pm Tel : (800) 528-1358 Apt : Appointment required Cost $: 38.20 Orange - Pro Image Solutions, Inc. 5796 Hoffner Ave Suite 603 Orlando, Fl, 32822 Hours : M-F. 8am-5pm Tel : (407) 282-4642 Apt : Appointment required Cost $: 39.25 FDLE LIVE SCAN VENDORS BY COUNTY OSCEOLA COUNTY Osceola - 1st Choice Live Scan Fingerprinting 989 Kennedy Blvd. Suite 204 Orlando, FL, 32810 Hours: Please call for an appointment Tel: (407) 476-SCAN (7226) Apt : Cost $: Osceola - AAA Fingerprinting of Central Florida 5764 N. Orange Blossom Trail Orlando, FL, 32810 Hours : 9am-5:30pm weekdays, no appoint. necessary. After hours and weekends by appoint. Tel : (407) 299-7328 Apt : No appointment necessary unless after hours or weekend Cost $: 43.00 Osceola - L-1 Enrollment Services 3050 Dyer Blvd Kissimmee, FL, 34741 Hours : M-F 10am-630pm Tel : (800) 528-1358 Apt : Appointment required Cost $: 38.20 SEMINOLE COUNTY Seminole - 1st Choice Live Scan Fingerprinting 989 Kennedy Blvd. Suite 204 Orlando, FL, 32810 Hours : Please call for an appointment Tel : (407) 476-SCAN (7226) Apt : Cost $: Seminole - AAA Fingerprinting of Central Florida 5764 N. Orange Blossom Trail Orlando, FL, 32810 Hours : 9am-5:30pm weekdays, no appoint. necessary. After hours and weekends by appoint. Tel : (407) 299-7328 Apt : No appointment necessary unless after hours or weekend Cost $: 43.00 Seminole - Daon Trusted Identity Services at The UPS Store 7025 County Road #46A Ste 1071 Lake Mary, FL, 32746 Hours : M-F 8am-6:30pm Sat 9am-3pm Tel : (703) 797-2562 Apt : Appointment Required Cost $: 38.25 Seminole - L-1 Enrollment Services 478 E Altamonte Dr #108 Altamonte Springs, FL, 32701 Hours : M-F 10am-4pm Tel : (800) 528-1358 Apt : Appointment required Cost $: 38.20 FLAGER COUNTY Flagler - L-1 Enrollment Services 800 Belle Terre Parkway, Ste 200 Palm Coast, FL, 32164 Hours : M-F 1030am-530pm Tel : (800) 528-1358 Apt : Appointment required Cost $: 38.20 FDLE LIVE SCAN VENDORS BY COUNTY BREVARD COUNTY Brevard - AAA Fingerprinting of Central Florida 5764 N. Orange Blossom Trail Orlando, FL, 32810 Hours : 9am-5:30pm weekdays, no appoint. necessary. After hours and weekends by appoint. Tel : (407) 299-7328 Apt : No appointment necessary unless after hours or weekend Cost $: 43.00 Brevard - Bridges BTC, Inc. 1694 Cedar St. Rockledge, FL, 32955 Hours : M-F 7:30am-12pm, 1pm-4:30pm Tel : (321) 690-3464 ext. 20 or 321-690-3464 ext. 34 Apt : Walk-in or by appointment Cost $: 50.00 Brevard - Daon Trusted Identity Services at The UPS Store 7777 N Wickham Rd Ste 12 Melbourne, FL, 32940 Hours : M-F 9am-6pm Sat 9am-4pm Tel : (703) 797-2562 Apt : Appointment Required Cost $: 38.25 Brevard - L-1 Enrollment Services 327 S Washington Ave Titusville, FL, 32796 Hours : M-Sat Hours vary Tel : (800) 528-1358 Apt : Appointment required Cost $: 38.20 Brevard - L-1 Enrollment Services 5445 Murrell Rd. Ste 102 Viera, FL, 32955 Hours : M-F 9am-5pm Sat. 10am-2pm Tel : (800) 528-1358 Apt : Appointment required Cost $: 38.20 VOLUSIA COUNTY Volusia - AAA Fingerprinting of Central Florida 5764 N. Orange Blossom Trail Orlando, FL, 32810 Hours : 9am-5:30pm weekdays, no appoint. necessary. After hours and weekends by appoint. Tel : (407) 299-7328 Apt : No appointment necessary unless after hours or weekend Cost $: 43.00 Volusia - L-1 Enrollment Services 944 Beveille Rd Daytona Beach, FL, 32119 Hours : Tu-F 10am-4pm Sat. 10am-2pm Tel : (800) 528-1358 Apt : Appointment required Cost $: 38.20 Volusia - L-1 Enrollment Services 725 S Nova Road Ormond Beach, FL, 32176 Hours : M-F 10am-4pm Sat. 10am-2pm Tel : (800) 528-1358 Apt : Appointment required Cost $: 38.20 Volusia - MacData Advantage Background Screening 609 S. Ridgewood Avenue Daytona Beach, FL, 32174 Hours : M-F 9:00 a.m. - 5:00 p.m. Tel : (386) 254-4888 Apt : Cost $: Volusia - Daon Trusted Identity Services at The UPS Store 2665 North Atlantic Ave Daytona Beach, FL, 32118 Hours : 0 Tel : (703) 797-2562 Apt : Appointment Necessary FDLE LIVE SCAN VENDORS BY COUNTY MONROE COUNTY Monroe - L-1 Enrollment Services 1200 Fourth Street Key West, FL, 33040 Hours: M-F 10am-5pm Tel: (800) 528-1358 Apt: Appointment required Cost $: 38.20 MIAMI-DADE COUNTY Dade - A Best Fingerprinting 1845 NW 17th Ave Miami, FL, 33125 Hours: Mon-Fri 9:00am-6:00pm walk-ins & Sat. 10:00am-1:00pm appointment only Tel: (305) 324-1011 Apt: No appointment necessary on weekdays, Sat. appointment only Cost $: 50.00 Dade - Advanced Screening Services, LLC. 1744 NE Miami Gardens Drive N. Miami, FL, 33179 Hours : Monday through Friday 8:30-6:30 pm Sat. 10:00-3:30pm First come first serve Tel : (954) 261-2887 Apt : No appointment necessary Cost $: 42.50 Dade - Apex Fingerprinting in Miami Lakes 15476 NW 77 Ct Miami Lakes, FL, 33016 Hours : M-F 9:00am-5:30pm Sat. 10:00am-2:00pm Sun-Closed Tel : (786) 663-0820 Apt : No appointment needed Cost $: 41.25 Dade - Daon Trusted Identity Services at The UPS Store 14629 SW 104 Street Miami, FL, 33186 Hours : M-F 8:30am-7pm, Sat 9am-4pm Tel : (703) 797-2562 Apt : Appointment required Cost $: 38.25 Dade - Daon Trusted Identity Services at The UPS Store 1825 Ponce De Leone Blvd Coral Gables, FL, 33134 Hours : M-F 8:30am-7pm, Sat 10am-5pm Tel : (703) 797-2562 Apt : Appointment required Cost $: 38.25 Dade - Daon Trusted Identity Services at The UPS Store 19821 NW 2nd Ave Miami Gardens, FL, 33169 Hours : M-F 8:30am-7pm, Sat 10am-3:30pm Tel : (703) 797-2562 Apt : Appointment required Cost $: 38.25 Dade - Fingerprint Express 2140 W Flagler Street Suite 206 Miami, FL, 33137 Hours : Tel : phone (305) 603-8128 fax (305) 444-9718 Apt : Cost $: Dade - Fingerprint Tech LLC 3735 SW 8th Street Suite 201 Coral Gables, FL, 33134 Hours : M-F 8am-4pm Tel : (305) 529-6000 Apt : No appointment necessary Cost $: Dade - Fingerprint Technologies 5200 SW 8 St. Suite 116 Coral Gables, FL, 33134 Hours : M-F 9am-6pm Tel : (305) 443-9148 Apt : No appointment needed (Saturday by appointment only) Cost $: 47.25 Dade - Fingerprint Technologies 555 East 25 St. Unit 110 Hialeah, FL, 33013 Hours : M-F 9am-5pm Tel : (786) 953-5999 Apt : No appointment needed Cost $: 47.25 Dade - L-1 Enrollment Services 1849 Flagler St Miami, FL, 33135 Hours : M-F 10am-4pm Tel : (800) 528-1358 Apt : Appointment required Cost $: 38.20 FDLE LIVE SCAN VENDORS BY COUNTY Dade - L-1 Enrollment Services 1581 West 49th Street Miami, FL, 33012 Hours : M-F 1030am-530pm Tel : (800) 528-1358 Apt : Appointment required Cost $: 38.20 Dade - L-1 Enrollment Services 6800 SW 40th St Miami, FL, 33155 Hours : M-F 10am-4pm Tel : (800) 528-1358 Apt : Appointment required Cost $: 38.20 Dade - L-1 Enrollment Services 3777 NE 163rd street North Miami Beach, FL, 33160 Hours : M-F 915am-530pm Sat. 915am-1230pm Tel : (800) 528-1358 Apt : Appointment required Cost $: 38.20 Dade - South Florida Fingerprinting 1550 S Dixie Hwy #212 Coral Gables, FL, 33146 Hours : M-Sat 730am-5pm Tel : (305) 661-1636 Apt : Appointment required Cost $: 45.00 Dade - 1st Screening & Fingerprinting LLC 15720 N. W. 37th Ct Miami Gardens, FL, 33054 Hours : By Appointments (weekdays, evening and weekend) Tel : (786) 529-1713 Apt : Appointment Necessary, Call for an Appointment Cost $: 60.00 Dade - Verification Consultants, Inc. 8145 W. 28th Ave, Suite 215 Hialeah, FL, 33016 Hours : Mon-Fri 8am- 4pm (walk-ins) Additional hours available with appointment. Tel : (305) 557-1500 Apt : No appointment necessary during walk-in hours Cost $: 47.50 Date Checked: _____________________ File Checklist: 1. Zero Tolerance exp _______________: ____________ 2. CPR/ First Aid exp _______________: ____________ 3. HIV/AIDS-Infection Control 4. Core Competencies-Intro to Developmental Disabilities 5. Core Competencies- Health & Safety 6. Core Assurances- Choices and Rights of Individuals 7. HIPPA (online) exp __________ : ____________ 8. Florida Administrative Code 65G-8 9. Overview Medication Administrative 65G-7 10. Development and Implementation of the Required Documentation of each Waiver Service 11. Person Centered and Implementation Plan for Providers 12. Medicaid Waiver Services Agreement and its Attachments as well as Coverage and Limitations Handbook and its Appendices 13. Social Security Card 14. FDLE exp __________ : ____________ 15. Local Law exp __________ : ____________ 16. APD Good Moral Affidavit exp __________ : ____________ 17. 2 Letters of Reference 18. Resume/ High School Diploma 19. Car Insurance exp __________ : ____________ 20. Car Registration exp __________ : ____________ 21. Florida ID exp __________ : ____________ 22. Light of Life Application W-9 COMMENTS: Here are some of the documents attached that you will need to begin. -Attached is our employment package. I’ll will help you understand these documents a bit better page by page. -First page you will see is the application. Fill one out according to the language that you prefer. You will also have the W-9 which will need to be filled out. -Next you will have two employment reference letters. You may use these or bring your own. They may be personal or from past employment. There will be a letter after this explaining that you must do your own taxes as an independent contractor. -Affidavit of Good Moral Character is next. Please take this to your local bank and they will notarize this for free! -Request of Local Law. This letter will explain that we are in need of a local law enforcement check. Please read as the pricing has changed: There will be three requests of local law forms. Chose the one that corresponds to your county. -Mandatory Trainings. There are some trainings that are requested to begin. The ones in BOLD are the most important ones and are mandatory to begin employment. Zero Tolerance, CPR & FIRST AID, HIV/AIDS with infection control, Health and Safety, and Intro to DD. Once you have these you may begin working. You can take these classes for FREE at APD (attached is the schedule) or you may take them ONLINE for $15 dollars each. (excluding CPR &HIV). I prefer taking them online because it’s much quicker and can be taken in the comfort of your home. If you desire to take them online feel free to contact me or e-mail me and I will assist you. -Next is the National Law Enforcement Check. It will say Live Scan Background Screening Submission Form. You must take this to one of the vendors listed below. The location and Pricing varies with vendor. They are all listed. -FILE CHECKLIST is last! This is what you file will need. Make sure to get the MOST IMPORTANT ones which were the ones I mentioned prior, you most important trainings, you affidavit, local law, live scan FDLE, application, references and w-9. Make sure to turn in anything else you may have as well. I know it’s a lot of information but if you have any questions or concerns feel free to contact us. I will better explain everything or assist you with signing up for classes, etc!! We look forward to seeing you here.! Thank you Ayxa R. Gomez Receptionist/Secretary Light of Life, Inc. "Lighting the World One Life at a Time" 1801 Sandy Creek Lane Suite 102 Orlando, Fl 32826 Office: (407) 568-8704 Fax: (407) 674-6808 Estos son los documentos que se necesita para comenzar. - Te mande nuestro paquete de empleo. Yo le ayudara a entender estos documentos un poco mejor página a página. -La primera página que se ve es la aplicación. Llene uno acuerdo a el idioma que prefiere. Usted también tendrá el W-9 que tendrá que llenar. -A continuación, tendrá dos cartas de recomendación de empleo. Usted puede usar estos o llevar su propia carta. Pueden ser personales. Habrá una carta explicando que usted debe hacer sus propios taxes. -Request of Local Law. Esta carta le explicara que estamos en la necesidad de un background check local. Los precios ha cambiado. Son 5 dólares. Mandarlo con ese papel, tiene que ser money order o personal check. Habrá tres formas de solicitud de las leyes locales. Usa el que corresponde a su condado. -Entrenamientos mandatorio. Hay algunos cursos que se necesitas para comenzar. Los que están en negra (BOLD) son los más importantes y con obligatorios para empezar a trabajar. Zero Tolerance (Cero Tolerancia), CPR, HIV/AIDS with infection control, Health and Safety, y Introduction to DD. Una vez que tenga estos entrenamientos y puede comenzar a trabajar. Usted puede tomar estas clases free en APD (adjunta esta el horario) o puede tomar la clase por computadora por $15 cada uno (con exclusión de CPR y HIV/AIDS) Yo prefiero tomarlos en la computadora porque es más rápido y se puede tomar en la comodidad de su hogar. Si usted desea tomar la clase por la computadora no dude en ponerse en contacto conmigo o enviarme un e-mail y le ayudaremos. -Lo siguiente es las huellas nacionales. Dira LIVE SCAN BACKGROUND SCREENING SUBMISSION FORM. Hay que llevar el papel que diga DCF y tu ID para uno de lo logares en el próximo papel. El precio y ubicación varia con el vendedor. Todos ellos están en la lista. -FILE CHECKLIST es el ultimo! Esto es lo que usted va a necesitar en total. Asegurase de obtener los más importantes, que con los que le mencionado antes. Son los entrenamientos más importantes, declaración jurada (local y nacional), referencias con la aplicación, y el W-9 (. Asegúrese de traer cualquier cosa que usted puede tener también. Sé que es una gran cantidad de información pero si usted tiene alguna pregunta o inquietud no dude en contactarte con nosotros. Le podar explicar todo mejor o ayudarle con inscribirse para las clases, Etc.! Esperamos contar con ustedes! Gracias! Ayxa R. Gomez Receptionist/Secretary Light of Life, Inc. "Lighting the World One Life at a Time" 1801 Sandy Creek Lane Suite 102 Orlando, Fl 32826 Office: (407) 568-8704 Fax: (407) 674-6808