Employment Application

okdhs

Program Type *

Select one:


Personnel or Applicant

Education

Yes   No

Do you have a high school diploma, General Education Development (GED) credential, or Licensing approved equivalent? *

Yes   No

When NO, are you in the process of obtaining a high school diploma, GED, or Licensing approved equivalent?


Background Investigation

Yes No

Are you required to register under the Sex Offenders Registration Act or Mary Rippy Violent Crime Offenders Registration Act? *

Yes No

Do you have pending charges, have you entered a plea of guilty or nolo contendere (no contest); or been convicted of any criminal activity involving gross irresponsibility or disregard for the safety of others; violence against an individual; sexual misconduct; child abuse or neglect; animal cruelty; or possession, sale, or distribution of illegal drugs? *

Signature of Personnel or Applicant

Yes No

I understand by completing this form a background investigation will occur prior to hire. *

Yes No
I understand my registration on the Child Care Registry (Restricted Registry) may occur when: *
  • a background investigation reveals a specified criminal history; or
  • an action against a child in care results in a confirmed or substantiated finding of abuse or neglect.
Yes No

I certify the information provided on this form is true and complete. *

Owner: Responsible Entity Director or Primary Caregiver Use Only

Complete during hiring process by owner, responsible entity, director, or primary caregiver:

Form must be submitted to Licensing within 2 weeks of employment. Please ensure all sections of the form are complete before submitting to licensing.