New Hire Paperwork - Bloomfield

New Jersey Universal Fingerprint Form
First Name
MI
Last Name
Contributor's Case # (Unique Identifier)
Miscellaneous
Daytime Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Social Security Number (Optional)
Date of Birth

MonthDayYear
Date
Height
Weight
Maiden of Alias Last Name
Place of Birth (US State if US Citizen; Country for all others)
Country of Citizenship
Home Address
City
State
Zip
FemaleMaleBoth
Hair Color
Eye Color
Asian/Pacific Islander (includes Asian Indian)BlackAmerican Indian/Alaska NativeWhite (includes Hispanic/Spanish Origin)Unknown
Occupation/ Position (with respect to Requirement)
Employer / Organization Name (with respect to the Requirement)
You MUST retain a copy of this form and the receipt of printing for your personal records.

APPLICANTS MUST NOT ALTER, SHARE, OR REUSE THIS FORM

CHILD ABUSE RECORD INFORMATION (CARI) CONSENT FORM STATE OF NEW JERSEY DEPARTMENT OF CHILDREN AND FAMILIES OFFICE OF LICENSING
CHILD CARE CENTER
New CenterRenewing CenterNew Staff Member Hired at a Licensed Center (Not Renewing)
Date Hire

MonthDayYear
Date
Center Name
Site Address
Mailing Address
Phone
Format: (000) 000-0000.
Director
Renewal Date

MonthDayYear
Date
ID#
Print your full name (first, middle, last)
Previous name, maiden name or nicknames
Date of name change or date of marriage

MonthDayYear
Date
Home address
City
State
Zip
Date of birth

MonthDayYear
Date
Race
Social Security number
Sex
NOTE: Pursuant to the Federal Privacy Act of 1974 (P.L. 93-579 the disclosure of your Social Security number is voluntary. Your Social Security number, race, date of birth, and sex will only be used for the purpose of conducting a Child Abuse Record Information background check as authorized by the State Child Care Center Licensing Law (N.J.S.A. 30:5B-1 to 15

Name

First NameLast Name
If none, check this box.
Child's Name

First NameMiddle NameLast Name
Child's Date of Birth

MonthDayYear
Date
Child's Name

First NameMiddle NameLast Name
Child's Date of Birth

MonthDayYear
Date
Child's Name

First NameMiddle NameLast Name
Child's Date of Birth

MonthDayYear
Date
Child's Name

First NameMiddle NameLast Name
Child's Date of Birth

MonthDayYear
Date
Child's Name

First NameMiddle NameLast Name
Child's Date of Birth

MonthDayYear
Date
If none, check this box.
Your previous address since 1990 and the dates you lived at each address.
Address
Resided from:
Month and Year
To:
Month and Year
Your previous address since 1990 and the dates you lived at each address.
Address
Resided from:
Month and Year
To:
Month and Year
Your previous address since 1990 and the dates you lived at each address.
Address
Resided from:
Month and Year
To:
Month and Year
Your previous address since 1990 and the dates you lived at each address.
Address
Resided from:
Month and Year
To:
Month and Year
All persons completing this form must read the following and sign below:

I consent to have the Department of Children and Families conduct a Child Abuse Record Information check to determine whether an allegation of child abuse or neglects has been substantiated against me. I certify that I am not currently being investigated for any allegation of child abuse or neglect. I understand that if a record of substantiated child abuse or neglect is found, or if I sign this consent form, I will not be permitted to sponsor or work at this or any other licensed child care center in New Jersey. I certify that all information I have given on this form is accurate and complete to the best of my knowledge.
Signature

Clear
Date

MonthDayYear
Date

Employee Confidentiality Agreement
Employee Signature

Clear

Employee Code of Conduct
Employee Name
Employee Signature

Clear
Date

MonthDayYear
Date

Ten Commandments of Customer Service
Applicant Signature

Clear
Date

MonthDayYear
Date

Employee Signature

Clear
Date

MonthDayYear
Date

Staff Emergency Form
Date (update as information changes)

MonthDayYear
Date
Emergency Card for:
Birth Month and Date
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cellphone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Address
Emergency Contact Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship
Emergency Contact Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship
In an emergency, do you have dependents that need to be picked up and/or cared for? If yes, please list their names and who we should contact to pick them up?
Medical Information
Allergies
Special Instructions
If you cannot breathe or need CPR/First Aid treatment, do you wish to have trained member of our staff assist you?
If you need to be taken to the emergency room, which hospital would you like to be taken to?
Would you like someone to accompany you?
Staff Signature

Clear