Form Cca-1114a Forff - Contractor Eligibility Verification
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1
2ARIZONA DEPARTMENT OF ECONOMIC SECURITY
CCA-1114A FORFF (4-17)
PLEASE
Child Care Administration
type or print
CONTRACTOR ELIGIBILITY VERIFICATION
all information
Section 1. Provider/Applicant Information and Verification
Completed and signed by the Applicant/Provider.
Name (Last, First, M.I.)
Other Name(s) (Previous names, aliases, nicknames, etc.)
Address (No., Street, Apt No.)
City
State
ZIP Code
Date of Birth (mm/dd/yyyy)
Place of Birth (City, State, Country)
Social Security Number
Failure to accurately report information on this form may result in termination of your Registration Agreement.
I attest, under penalty of perjury, that I am (check one of the following):
A citizen or national of the United States
A lawful permanent resident – (Alien Registration Number/USCIS Number):
A legal alien authorized to work until
Alien No. or Admission No.
Provider/Applicant’s Signature
Date (mm/dd/yyyy)
Section 2. Preparer and/or Translator Certification
Completed and signed if the above section is prepared by a person other than the Provider/Applicant.
I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge
the information is true and correct.
Preparer/Translator’s Name (Last, First, M.I.)
Preparer/Translator’s Signature
Address (No., Street, Apt No.)
City
State
ZIP Code
Date (mm/dd/yyyy)
Section 3. Child Care Administration Review and Verification
Completed and signed by the Certification Specialist.
Examine one document from List A OR examine one document from each List B AND List C, as listed on page 2 of this
form. Record the title, number, expiration date, if any, of the documents.
List A
OR
List B
AND
List C
DOCUMENT TITLE
DOCUMENT TITLE
DOCUMENT TITLE
ISSUING AUTHORITY
ISSUING AUTHORITY
ISSUING AUTHORITY
DOCUMENT NUMBER
DOCUMENT NUMBER
DOCUMENT NUMBER
EXPIRATION DATE (MM/DD/YYYY)
EXPIRATION DATE (MM/DD/YYYY)
EXPIRATION DATE (MM/DD/YYYY)
Certification Specialist’s Name (Last, First, M.I.)
Certification Specialist’s Signature
Date (mm/dd/yyyy)
See page 2 for EOE/ADA/LEP/GINA disclosures
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