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Link to Role and Business Information

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an early learning or school age care program and role

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a professional development provider and role

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An Early Learning or School Age Care Program and Role

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My role Is

I Work at

Thank you for your interest in being considered for the role of a substitute and/or assistant. Please contact the provider directly so that they can initiate the proper process as required by the Department. If the provider has questions about the proper process they may call 1-866-448-4605. You must be approved by the Department prior to being involved with child care in a Child Development Home or a Child Care Home.

Complete Business Information

Business Information

Organization Legal Name

Doing Business As

Parent Corporation

Form of Business Entity

State of Incorporation/ Organization

Business Web Address

Organization Primary Address

Address 1

Address 2

City

County

State

Zip Code

Zip ext

Organization Primary Phone

Buisness Phone Number

Buisness Phone Extension

When applicable, enter the addresses of other major offices and facilities that are part of this business:

Address 1

Address 2

City

County

State

Zip Code

Zip ext

When applicable, enter the phone numbers of other major offices and facilities that are part of this business:

Phone Number

Phone Extension

Organization Employees Info

Number of Employees

Number of Years in Business

Primary Focus of Business

Federal Tax ID

Iowa’s Business Registration Date

Iowa Counties Served by Business

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County Name	Action

Manager Details

Manager First Name

Manager Last Name

Manager Title

Manager Phone Number

Manager Phone Ext

Manager Email

This professional development providing organization is

Employment Information

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Position Title:

From: To:

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Place of Employment (Business Name)

Position Title

Role (Job Category)

Position Start Date

Position End Date

Reason For Departure

Work Pertained To

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Work Pertains To	Action

Employment Benefits Offered

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Employment Benefits Offered	Action

Wage Information

Wage Type

Wage

Hours Worked Per Week

Months Worked Per Year

Employment Documents

Document Type

I certify that the information I am entering is correct and complete to the best of my knowledge.

Education Information

Add/Update Education Information

Completed On:

()

Degree Completion Date:

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Completed On

Degree Completion Date

Attachment(s)

Verification(s)

Verified By		Verification Method	Comments	Verified By Organization	Verified On

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Degree Type:

Comments:

College Courses

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(College Course)

Course Completion Date:

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Course Completion Date

Course Detail

Course Type

Course Number

Credit Type

Number of Credits

Attachment(s)

Verification(s)

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Course Type:

Credential & License Information

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Issuance Date

Awarding Entity

Awarding State

Validity

Duration

Expiration Date

Attachment(s)

Verification(s)

Verified By		Comments	Verified By Organization	Verified On

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Adult Educator and TA Specialist Profile

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My Professional Competency Level

Number of miles I'm willing to travel:

Subject Area Expertise

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Subject Area Expertise	Action

Competency Areas of Expertise

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Competency Areas of Expertise	Action

Counties I'm available to provide services in:

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County	Action

Type Of TA Provided

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County	Action

Languages Qualified to provide services in:

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Language	Action

Resume

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Content Expert in:

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Content Expertise	Action

Schedule of Availability

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To Time

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Link to Role and Business Information

A Different Role

My role Is

An Early Learning or School Age Care Program and Role

My role Is

I Work at

If you need to complete preservice training requirements, please go back and choose the “Completing Preservice/Orientation” option for My Role Is : Review your Profile to make sure you have all the information completed and up to date. User Profile

If you have not submitted an application to become a Registered Child Development Home: Please do the following:

Learn about becoming a Registered Child Development Home provider by reviewing the Child Development Home Registration Guidelines: https://ccmis.dhs.state.ia.us/providerportal/DocumentsandForms.aspx

Fill out all information in your Profile User Profile

Submit an application to become a Registered Child Development Home Provider by contacting CCR&R: https://iowaccrr.org/providers/AP/

A Professional Development Provider and Role

My role Is

I Work at

Complete Business Information

Business Information

Organization Primary Address

Organization Primary Phone

When applicable, enter the addresses of other major offices and facilities that are part of this business:

When applicable, enter the phone numbers of other major offices and facilities that are part of this business:

Organization Employees Info

Iowa Counties Served by Business

Manager Details

Employment Information

Position Title:

From: To:

There is no employment information entered.

Education Information

Completed On:

()

Degree Completion Date:

There is no education information entered.

College Courses

(College Course)

Course Completion Date:

There is no college course information entered.

Credential & License Information

There is no credential/license information entered.

There is no Credential/License Info for this user to Verify

Adult Educator and TA Specialist Profile

Subject Area Expertise

Competency Areas of Expertise

Counties I'm available to provide services in:

Type Of TA Provided

Languages Qualified to provide services in:

Resume

Content Expert in:

Schedule of Availability