ࡱ> KMJ 8bjbjVV :@<<h ..qqqqq8\L_.e*jl8/EqjjqqJJJ:qqJJJJ+l:J/0_J) 2) J) qJtJJ_) . 7: OCFS 4622 (12/2010) NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES DIVISION OF CHILD CARE SERVICES NOTICE TO EXPUNGE ASSOCIATED FINGERPRINT CARDS This form should be completed immediately, when any person(s) who were fingerprinted as: a day care provider, assistant, household member over the age of 18, Day Care Center or School-Age program employee or volunteers judged to have regular and substantial contact, are separated from service (no longer part of the day care program). The purpose of this form is to provide the Office of Children and Family Services (OCFS) with information that OCFS will use to terminate the search and retain function. Search and Retain allows the Division of Child Care Services (DCCS) Regional Office to be notified of arrests in New York State throughout the period that a day care provider, assistant, household member over the age of 18, Day Care Center or School-Age program employee or volunteers judged to have regular and substantial contact remain on record as open/active with DCCS. Complete a separate form for each person who was fingerprinted and is no longer associated with your program. [PLEASE PRINT CLEARLY] Name (Last):  FORMTEXT      First:  FORMTEXT      Middle:  FORMTEXT      Sex  FORMCHECKBOX  MALE  FORMCHECKBOX  FEMALEDate of Birth (mo./day/year):  FORMTEXT      Date TErminated from program:  FORMTEXT      Program NAME:  FORMTEXT      Program ID/ CCFS #:  FORMTEXT      Program Address (Street No., Kjk   ; < ˾uh^uhuhQh#yh'OJQJ^Jh#yOJQJ^Jh#yh#yOJQJ^Jh#yh</OJQJ^Jh#yh</5OJQJ^Jh#yhYZ5OJQJ^J hBCJ h</CJh</CJOJQJ^Jh</hLXh</CJOJQJ\^JhdCJOJQJ\^Jh</CJOJQJ\^JhYZCJOJQJ\^Jh</5CJOJQJ^J$Kk 0 2 4 6     F H b d8$IfgdBq$If$a$gdYZ$a$$a$< = @ A E F K m 0 : M O ( 0 2 4 6 ˽˽殢uukaSh8hG&;OJQJ^JhLXOJQJ^Jh</OJQJ^Jh#yh#yCJOJQJ^Jh#yh'CJOJQJ^Jh#yhYZCJOJQJ^Jh#yCJOJQJ^Jh#yh</CJOJQJ^Jh#yh</5OJQJ^Jh#yhYZ5OJQJ^Jh#yh#yOJQJ^Jh#yh</OJQJ^Jh#yhvOOJQJ^J6 p x      F H b d x z | Ĺq_Eq2jhBqh</;CJOJQJU^JaJ#hBqh</;CJOJQJ^JaJ,jhBqh</;CJOJQJU^JaJh</;CJOJQJ^Jh</CJOJQJ^Jhdh</OJQJ^JhLX5OJQJ^JhG&5OJQJ^Jh</5OJQJ^Jh8hYZ5;OJQJ^J!h8h</5;>*OJQJ^Jh8h</5;OJQJ^J| $̺̺̺̺y̺obM< hBqhYZCJOJQJ^JaJ)jhBqhYZCJOJQJU^JaJhYZ;CJOJQJ^Jh</OJQJ^J2jhBqh</;CJOJQJU^JaJ2jthBqh</;CJOJQJU^JaJh</;CJOJQJ^J#hBqh</;CJOJQJ^JaJ,jhBqh</;CJOJQJU^JaJ7jhBqh</;CJOJQJU^JaJmHnHu 4f[P==$d8$Ifa$gdBq $Ifgd</kd`$$Ifl4F !x'_0'6    4 laf4ytBqd8$IfgdBq$If$&(46RTVdf{iO{3{i7jhBqhYZ;CJOJQJU^JaJmHnHu2jhBqhYZ;CJOJQJU^JaJ#hBqhYZ;CJOJQJ^JaJ,jhBqhYZ;CJOJQJU^JaJhYZ;CJOJQJ^JhYZOJQJ^J/jhBqhYZCJOJQJU^JaJ hBqhYZCJOJQJ^JaJ)jhBqhYZCJOJQJU^JaJ/j7hBqhYZCJOJQJU^JaJf02:kd$$Ifl4\ x'i  v 0'64 laf4ytBq $Ifgddd8$IfgdBq $Ifgd</  ",.02@NPdfhɯۓہwj]F,F2jhBqhYZ;CJOJQJU^JaJ,jhBqhYZ;CJOJQJU^JaJhYZ;CJOJQJ^JhLX;CJOJQJ^JhYZOJQJ^J#hBqhYZ;CJOJQJ^JaJ7jhBqhd;CJOJQJU^JaJmHnHu2jhBqhd;CJOJQJU^JaJ#hBqhd;CJOJQJ^JaJ,jhBqhd;CJOJQJU^JaJhd;CJOJQJ^J2Nv$(L(nb d8$IfgdBqxkd$$Ifl*0x'nv 0'64 laytBqd8$IfgdBq $IfgdYZhrtv($(̺oSI<:Uhd;CJOJQJ^Jh</OJQJ^J7jhBqh</;CJOJQJU^JaJmHnHu2jvhBqh</;CJOJQJU^JaJ,jhBqh</;CJOJQJU^JaJhYZ;CJOJQJ^JhLX;CJOJQJ^J#hBqh</;CJOJQJ^JaJ,jhBqhYZ;CJOJQJU^JaJ7jhBqhYZ;CJOJQJU^JaJmHnHu Street Address):  FORMTEXT      City:  FORMTEXT      State:  FORMTEXT      Zip Code:  FORMTEXT      Contact Person:  FORMTEXT      Phone #:  FORMTEXT      Signature of Person completing this form:  FORMTEXT      Date$(&(:(<(>(H(J(L(N(\(^(r(t(v(((((((((((((((׽חp׊V׊2jhBqhLX;CJOJQJU^JaJ2jhBqhLX;CJOJQJU^JaJhLX;CJOJQJ^JhLXOJQJ^J7jhBqhLX;CJOJQJU^JaJmHnHu2jhBqhLX;CJOJQJU^JaJ#hBqhLX;CJOJQJ^JaJ,jhBqhLX;CJOJQJU^JaJL(N(\((((((d8$IfgdBq $Ifgd</ekd $$Ifl*x''0'64 laytBq((((((()).)0)2)<)>)@)R)T)ϳϡsaGs+sas7jhBqhd;CJOJQJU^JaJmHnHu2j hBqhd;CJOJQJU^JaJ#hBqhd;CJOJQJ^JaJ,jhBqhd;CJOJQJU^JaJhd;CJOJQJ^JhLXOJQJ^J#hBqhLX;CJOJQJ^JaJ7jhBqhLX;CJOJQJU^JaJmHnHu,jhBqhLX;CJOJQJU^JaJ2jhBqhLX;CJOJQJU^JaJ(()@)R)z)ti[i[d8$IfgdBq $Ifgd</kd $$Ifl*F,x'n*L 0'6    4 laytBqT)h)j)l)v)x)z)|)))))))))*888888(8*8,8.808Ӽ행omSIhLX5B*ph2j hBqhd;CJOJQJU^JaJU2jN hBqhd;CJOJQJU^JaJhd;CJOJQJ^JhdOJQJ^J7jhBqhd;CJOJQJU^JaJmHnHu,jhBqhd;CJOJQJU^JaJ2j; hBqhd;CJOJQJU^JaJ#hBqhd;CJOJQJ^JaJz)|)))8,8|n|nd8$IfgdBq $Ifgd</xkd $$Ifl*0x'nv 0'64 laytBq:  FORMTEXT       This form should be submitted to your licensing representative or registrar     ,8.80828488uu $$Ifa$gdLX$Ifxkd6 $$Ifl*0x'nv 0'64 laytBq0828488888888888888ĺh_pjh_pUhYZOJQJ^JhLXhLX5OJQJ^Jhc$hLX5OJQJ^Jhc$hc$5OJQJ^JhLXhLX5hG&5B*ph8888888888888gdBekd $$Ifl7x''0'64 laytB 8P:p./ =!"#`$`% DptDText1vDText14vDText15$$If!vh5_55#v_#v#v:V l40'65_55/ / 4f4ytBqtDeCheck1tDeCheck2tDText3tDText3$$If!vh55i 5 5v #v#vi #v #vv :V l40'655i 5 5v / / / 4f4ytBqtDText6tDText6$$If!vh5n5v #vn#vv :V l*0'65n5v / 4ytBqtDText2$$If!vh5'#v':V l*0'65'/ 4ytBqvDText11vDText12vDText13$$If!vh5n5*5L #vn#v*#vL :V l*0'65n5*5L / 4ytBqtDText8tDText9$$If!vh5n5v #vn#vv :V l*0'65n5v 4ytBqtDText8tDText9$$If!vh5n5v #vn#vv :V l*0'65n5v 4ytBq$$If!vh5'#v':V l70'65'/ 4ytB^ 666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH B@B  Heading 1$$@&a$5CJN@N  Heading 2$$x@&a$5OJQJ^JJJ  Heading 3 $@&5OJQJ\^JDA D Default Paragraph FontVi@V 0 Table Normal :V 44 la (k ( 0No List 8B@8  Body Text$a$CJHH d0 Balloon TextCJOJQJ^JaJNN d0Balloon Text CharCJOJQJ^JaJPK![Content_Types].xmlj0Eжr(΢Iw},-j4 wP-t#bΙ{UTU^hd}㨫)*1P' ^W0)T9<l#$yi};~@(Hu* Dנz/0ǰ $ X3aZ,D0j~3߶b~i>3\`?/[G\!-Rk.sԻ..a濭?PK!֧6 _rels/.relsj0 }Q%v/C/}(h"O = C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_6LR7`0̞O,En7Lib/SeеPK!kytheme/theme/themeManager.xml M @}w7c(EbˮCAǠҟ7՛K Y, e.|,H,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+& 8PK!Ptheme/theme/theme1.xmlYOo6w toc'vuر-MniP@I}úama[إ4:lЯGRX^6؊>$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! 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