employment application - light of life, inc

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]

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

Employment Application

1801 Sandy Creek Lane, Suite 102 Orlando, Fl 32826 Phone: 407-568-8704 Fax: 407-674-6808

APPLICATION FOR EMPLOYMENT APPLICANT MAY BE CHECKED FOR CRIMINAL BACKGROUND

Está usted 18 años o más Telefono: ( ) _____ ______________ Está usted un U.S. Ciudadano o un extranjero autorizado a trabajar

Si □ No □ Celular: ( ) ____ __________________ en el U.S.A Si□ No □

En el caso de la emergencia Dirección: 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 □ No □ ¿Cuándo? ¿Quién le refirió a esta agencia?

□ Agencia del empleado □ Publicidad del periódico □ Amigo □ 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

TIPO DE ESCUELA

NOMBRE DE LA ESCUELA

LOCALIZACIÓN

(Dirección completa del correo)

NÚMERO DE LOS AÑOS

TERMINADO

PRINCIPAL &

GRADO

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

AN EQUAL OPPORTUNITY EMPLOYER A DRUG –FREE WORKPLACE

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:

“Encendiendo el mundo una vida a la Vez”


APPLICATION FOR EMPLOYMENT APPLICANT MAY BE CHECKED FOR CRIMINAL BACKGROUND

Are you 18 years or older Phone: ( ) ______ _______________ Are you a U.S. Citizen or an Alien authorized to work

Yes □ No □ Cell: ( ) ____ __________________ in the U.S.A. Yes □ No □ In case of Emergency Address 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? Yes □ No □ When? Who referred you to this agency?

□ Employee Agency □ Newspaper Advertising □ 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

MAJOR &

DEGREE

Needed High School

College

Bus. or Trade School

GENERAL English Language Knowledge: Speaks □ Read □ Write □ Spanish Language Knowledge: Speaks □ Read □ Write □ Special Trainings/Skills

Name: (Last Name First)

Today's Date Social Security DOB

Present Address

City

State and Zip Code

Previous Address

City State and Zip Code

E-Mail:

AN EQUAL OPPORTUNITY EMPLOYER A DRUG –FREE WORKPLACE

“Lighting the World One Life at a Time”

SubstituteForm W-9

(Rev. March 2002)

Request for Taxpayer

Identification Number and Certification

Give form to the

requester. Do not

send to the IRS.

Name (See Specific Instructions on page 2.)

Business name, if different from above. (See Specific Instructions on page 2.)

Individual/Sole Proprietor Corporation Partnership Other Ź Check appropriate box:

LLC filing as Sole Proprietor LLC filing as Corporation LLC filing as Partnership

Address (number, street, and apt. or suite no.) Requestor’s name and address (optional)

City, state, and ZIP code

Ple

ase p

rin

t o

r ty

pe

Part I Taxpayer Identification Number (TIN) List account number(s) here (optional)

Social security number

Part IIor

Employer identification number

For U.S. Payees Exempt FromBackup Withholding (See theinstructions on page 2.)

Enter your TIN in the appropriate box. Forindividuals, 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 youremployer identification number (EIN). If you do nothave a number, see How to get a TIN on page 2.Note: If the account is in more than one name, seethe chart on page 2 for guidelines on whose numberto enter. Ź

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 InternalRevenue 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 hasnotified 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 backupwithholding 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 retirementarrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you mustprovide your correct TIN. (See the instructions on page 2)

Sign

HereSignature of

U.S. person Ź Date Ź

Purpose of Form

A person who is required to file an informationreturn with the IRS must get your correcttaxpayer identification number (TIN) to report,for example, income paid to you, real estatetransactions, mortgage interest you paid,acquisition or abandonment of securedproperty, cancellation of debt, or contributionsyou made to an IRA.Use Form W-9 only if you are a U.S. person(including a resident alien), to give your correctTIN to the person requesting it (the requester)and, when applicable, to:1. Certify the TIN you are giving is correct (or

you are waiting for a number to be issued),2. Certify you are not subject to backup

withholding, or3. Claim exemption from backup withholding

if you are a U.S. exempt payee.If you are a foreign person, use theappropriate Form W-8. See Pub. 515,Withholding of Tax on Nonresident Aliens andForeign Corporations.Note: If a requester gives you a form otherthan Form W-9 to request your TIN, you mustuse the requester’s form if it is substantiallysimilar to this Form W-9.

What is backup withholding? Personsmaking certain payments to you must withholdand pay to the IRS 31% of such paymentsunder certain conditions. This is called “backupwithholding.” Payments that may be subject tobackup withholding include interest, dividends,broker and barter exchange transactions,rents, royalties, non-employee pay, and certainpayments from fishing boat operators. Realestate transactions are not subject to backupwithholding.If you give the requester your correct TIN,make the proper certifications, and report allyour taxable interest and dividends on your taxreturn, payments you receive will not besubject to backup withholding. Payments youreceive will be subject to backupwithholding if:

1. You do not furnish your TIN to therequester, or2. You do not certify your TIN when required

(see the Part III instructions on page 2 fordetails), or3. The IRS tells the requester that you

furnished an incorrect TIN, or4. The IRS tells you that you are subject to

backup withholding because you did not reportall your interest and dividends on your taxreturn (for reportable interest and dividendsonly), or

5. You do not certify to the requester thatyou are not subject to backup withholdingunder 4 above (for reportable interest anddividend accounts opened after 1983 only).Certain payees and payments are exemptfrom backup withholding. See the Part IIinstructions and the separate Instructions forthe Requester of Form W-9.

Penalties

Failure to furnish TIN. If you fail to furnishyour correct TIN to a requester, you aresubject to a penalty of $50 for each suchfailure unless your failure is due to reasonablecause and not to willful neglect.Civil penalty for false information withrespect to withholding. If you make a falsestatement with no reasonable basis thatresults in no backup withholding, you aresubject to a $500 penalty.Criminal penalty for falsifying information.Willfully falsifying certifications or affirmationsmay subject you to criminal penalties includingfines and/or imprisonment.

Misuse of TINs. If the requester discloses oruses TINs in violation of Federal law, therequester may be subject to civil and criminalpenalties.

Substitute Form W-9 (Rev. 03-2002)

Substitute Form W-9 (Rev. 03-2002) Page 2

Specific InstructionsName. If you are an individual, you mustgenerally enter the name shown on your socialsecurity card. However, if you have changedyour last name, for instance, due to marriagewithout informing the Social SecurityAdministration of the name change, enter yourfirst name, the last name shown on your socialsecurity card, and your new last name.

If the account is in joint names, list first andthen circle the name of the person or entitywhose number you enter in Part I of the form.

Sole proprietor. Enter your individual nameas shown on your social security card on the“Name” line. You may enter your business,trade, or “doing business as (DBA)” name onthe “Business name” line.

Limited liability company (LLC). If you area single-member LLC (including a foreign LLCwith a domestic owner) that is disregarded asan entity separate from its owner underTreasury regulations section 301.7701-3, enterthe owner’s name on the “Name” line. Enterthe LLC’s name on the “Business name” line.

Caution: A disregarded domestic entity thathas a foreign owner must use the appropriateForm W-8. Other entities. Enter your business name asshown on required Federal tax documents onthe “Name” line. This name should match thename shown on the charter or other legaldocument creating the entity. You may enterany business, trade, or DBA name on the“Business name” line.

Part I—Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. If you are a resident alien and you do nothave and are not eligible to get an SSN, yourTIN is your IRS individual taxpayer identificationnumber (ITIN). Enter it in the social securitynumber box. If you do not have an ITIN, seeHow to get a TIN below.

If you are a sole proprietor and you have anEIN, you may enter either your SSN or EIN.However, the IRS prefers that you use yourSSN.

If you are an LLC that is disregarded as anentity separate from its owner (see Limitedliability company (LLC) above), and areowned by an individual, enter your SSN (or“pre-LLC” EIN, if desired). If the owner of adisregarded LLC is a corporation, partnership,etc., enter the owner’s EIN.

Note: See the chart on this page for furtherclarification of name and TIN combinations.How to get a TIN. If you do not have a TIN,apply for one immediately. To apply for anSSN, get Form SS-5, Application for a SocialSecurity Card, from your local Social SecurityAdministration office. Get Form W-7,Application for IRS Individual TaxpayerIdentification Number, to apply for an ITIN orForm SS-4, Application for EmployerIdentification Number, to apply for an EIN. Youcan get Forms W-7 and SS-4 from the IRS bycalling 1-800-TAX-FORM (1-800-829-3676) orfrom the IRS’s Internet Web Site atwww.irs.gov.

If you do not have a TIN, write “Applied For”in the space for the TIN, sign and date the form,and give it to the requester. For interest anddividend payments, and certain paymentsmade with respect to readily tradableinstruments, generally you will have 60 days toget a TIN and give it to the requester beforeyou are subject to backup withholding onpayments. The 60-day rule does not apply toother types of payments. You will be subject to

backup withholding on all such payments untilyou provide your TIN to the requester.

Note: Writing “Applied For” means that youhave already applied for a TIN or that youintend to apply for one soon.

Part II—For U.S. Payees Exempt FromBackup Withholding

Individuals (including sole proprietors) are notexempt from backup withholding. Corporationsare exempt from backup withholding forcertain payments, such as interest anddividends. For more information on exemptpayees, see the separate Instructions for theRequester of Form W-9.

If you are exempt from backup withholding,you should still complete this form to avoidpossible erroneous backup withholding. Enteryour correct TIN in Part I, write “Exempt” inPart II, and sign and date the form.

If you are a nonresident alien or a foreignentity not subject to backup withholding, givethe requester the appropriate completed FormW-8.

Part III—Certification

To establish to the withholding agent that youare a U.S. person, or resident alien, sign FormW-9. You may be requested to sign by thewithholding agent even if items 1, 3, and 5below indicate otherwise.

For a joint account, only the person whoseTIN is shown in Part I should sign (whenrequired).

1. Interest, dividend, and barter exchangeaccounts opened before 1984 and brokeraccounts considered active during 1983.You must give your correct TIN, but you do nothave to sign the certification.

2. Interest, dividend, broker, and barterexchange accounts opened after 1983 andbroker accounts considered inactiveduring 1983. You must sign the certification orbackup withholding will apply. If you aresubject to backup withholding and you aremerely providing your correct TIN to therequester, you must cross out item 2 in thecertification before signing the form.

3. Real estate transactions. You must signthe certification. You may cross out item 2 ofthe certification.

4. Other payments. You must give yourcorrect TIN, but you do not have to sign thecertification unless you have been notified thatyou have previously given an incorrect TIN.“Other payments” include payments made inthe course of the requester’s trade or businessfor rents, royalties, goods (other than bills formerchandise), medical and health careservices (including payments to corporations),payments to a non-employee for services,payments to certain fishing boat crewmembers and fishermen, and gross proceedspaid to attorneys (including payments tocorporations).

5. Mortgage interest paid by you,acquisition or abandonment of securedproperty, cancellation of debt, qualifiedstate tuition program payments, IRA orMSA contributions or distributions, andpension distributions. You must give yourcorrect TIN, but you do not have to sign thecertification.

Privacy Act Notice

Section 6109 of the Internal Revenue Coderequires you to give your correct TIN topersons who must file information returns with

the IRS to report interest, dividends, and certainother income paid to you, mortgage interest youpaid, the acquisition or abandonment of securedproperty, cancellation of debt, or contributions youmade to an IRA or MSA. The IRS uses the numbersfor identification purposes and to help verify theaccuracy of your tax return. The IRS may alsoprovide this information to the Department of Justicefor civil and criminal litigation, and to cities, states,and the District of Columbia to carry out their taxlaws.

You must provide your TIM whether or not you arerequired to file a tax return. Payers must generallywithhold 31% of taxable interest, dividend, andcertain other payments to a payee who does notgive a TIN to a payer. Certain penalties may alsoapply.

What Name and Number ToGive the RequestorFor this type of account: Give name and SSN of:

1. Individual The individual2. Two or more individuals The actual owner of the (joint account) account or, if combined

funds, the first individualon the account

1

3. Custodian account of a The Minor 2

minor (Uniform Gift to Minors Act)4. a. The usual revocable The grantor-trustee

1

savings trust (grantor is also trustee) b. So-called trust The actual owner

1

account that is not a legal or valid trust under state law5. Sole proprietorship The owner

3

For this type of account: Give name and EIN of:

6. Sole Proprietorship The owner 3

7. A valid trust, estate, or Legal entity 4

pension trust8. Corporate The corporation9. Association, club, The organization religious, charitable, educational, or other tax-exempt organization10. Partnership The partnership11. A broker or registered The broker or nominee nominee12. Account with the The public entity Department of Agriculture in the name of a public entity (such as a state or local government, school district, or prison) that receives agricultural program payments

1 List first and circle the name of the person whose number

you furnish. If only one person on a joint account has anSSN, that person’s number must be furnished.

2 Circle the minor’s name and furnish the minor’s SSN.

3 You must show your individual name, but you may also

enter your business or “DBA” name. You may use eitheryour SSN or your EIN (if you have one).

4 List first and circle the name of the legal trust, estate, or

pension trust. (Do not furnish the TIN of the personalrepresentative or trustee unless the legal entity itself is notdesignated in the account title.)

Note: If no name is circled when more thanone name is listed, the number will beconsidered to be that of the first name listed.

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 4 5

Efficiency (Eficiencia) 1 2 3 4 5

Determination (Determinacion) 1 2 3 4 5

Organization (Organizacion) 1 2 3 4 5

Time Management (Manejo de Tiempo) 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


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 1. Zero Tolerance o 2. CPR and First Aid o 3. HIV/AIDS-Infection Control o 4. Core Competencies-Intro to Developmental Disabilities and Health & Safety o 5. Medication Administration o 6. Core Assurances- Choices and Rights of Individuals o 7. HIPPA (online at http://www.dcf.state.fl.us/admin/training.shtml)

-click on HIPAA Information and Action o 8. Florida Administrative Code 65G-8 o 9. Overview Medication Administrative 65G-7 o 10. Medicaid Waiver Services Agreement and its Attachment as well as Coverage and

Limitations Handbook and its Appendices. o 11. Development & Implementation of the Required Documentation of each Waiver Service o 12. Use of a Person-Centered Approach to Service Delivery o 13. Reactive Strategies Procedures

Sincerely,


http://www.dcf.state.fl.us/admin/training.shtml

https://floridadcf.adobeconnect.com/hipaabasics2011_hrtsmod214_internet/


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, chasque 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 1. Zero Tolerance o 2. CPR and First Aid o 3. HIV/AIDS-Infection Control o 4. Core Competencies-Intro to Developmental Disabilities and Health & Safety o 5. Medication Administration o 6. Core Assurances- Choices and Rights of Individuals o 7. HIPPA (por internet: http://www.dcf.state.fl.us/admin/training.shtml)

- chasque encendido HIPAA Information and Action o 8. Florida Administrative Code 65G-8 o 9. Overview Medication Administrative 65G-7 o 10. Medicaid Waiver Services Agreement and its Attachment as well as Coverage and Limitations

Handbook and its Appendices o 11. Development & Implementation of the Required Documentation of each Waiver Service o 12. Use of a Person-Centered Approach to Service Delivery o 13.Reactive Strategies Procedures

Sinceramente,

Gisela Ramos Presidente /Founder

http://www.dcf.state.fl.us/admin/training.shtml

https://floridadcf.adobeconnect.com/hipaabasics2011_hrtsmod214_internet/


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,


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:

Requested by: Gisela Ramos Agency of Health Care Administration

1801 Sandy Creek Lane, Suite 102 Orlando, FL 32826


Osceola County To: Osceola County Sheriff’s Office 2601 E. Irlo Bronson Memorial Hwy Kissimmee, Florida 34744-4494


First Name: _____________________________________

Middle Name: ___________________________________

Last Name: ______________________________________

Date of Birth: ____________________________________

Social Security: __________________________________

Race/Sex: _______________________________________





Seminole County To: Seminole County Sheriff’s Office 100 Bush Boulevard Sanford, Florida 32773-6706


First Name: _____________________________________

Middle Name: ___________________________________

Last Name: ______________________________________

Date of Birth: ____________________________________

Social Security: __________________________________

Race/Sex: _______________________________________




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

Rick Scott Governor David E. Wilkins Secretary

State of Florida Department of Children and Families

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

2. DCF Agency Identifier (ORI)# FL92----Z This is a nine digit number beginning with FL92 and ending with the letter “Z”.

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:

x A valid ORI entered into the Controlling Agency Identifier field (this may also be the Requesting Agency field) on the Transaction Screen, and

x 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.

http://www.dcfbackgroundscreening.com/

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FL921811Z

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0748-1242Z

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http://www.fdle.state.fl.us/

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


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


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


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


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


6800 SW 40th St

Miami, FL, 33155

Hours : M-F 10am-4pm

Tel : (800) 528-1358


Cost $: 38.20


3777 NE 163rd street

North Miami Beach, FL, 33160

Hours : M-F 915am-530pm Sat. 915am-1230pm

Tel : (800) 528-1358


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


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

employment application - light of life, inc

Documents