Form Cca-1228a Forff - Provider Home Certification Direct Service Position (Certification Form) Page 2

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CCA-1228A FORFF (12-16)-PAGE 2
Name:
Date of Birth:
DIRECT SERVICE POSITION SUPPLEMENT #1
[Additional Address(es)]
The Direct Service Position Supplement #1 is to be completed by individuals who have completed the Direct Service Po-
sition form and have indicated that they have resided in other state(s) in the past five years. The information provided will
be used by the Department to complete and submit the Request for Search for Background Checks form. This information
is confidential and will be retained by the Department as such with the exception that the Department is required to attach
it to the background check request identified above.
I certify that I have resided in other state(s) in the past five (5) years and that the required information is indicated below. It
contains complete address(es) which include number, street, city, state, zip code and dates during which I resided there.
Please print or type.
DATE
ADDRESS

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