INSTRUCTIONS: ARIZONA CERTIFICATION FOR DIRECT SERVICE POSITION (Form ACY-1287A)

If you apply for a position with the Arizona Department of Economic Security providing direct service to children or vulnerable individuals, you will be required to complete a form ACY-1287A. This document can be obtained from the website maintained by the Arizona Department of Economic Security.

Arizona Certification For Direct Service Position ACY-1287A Step 1: In the first blank box, enter your last name, first name and middle initial.

Arizona Certification For Direct Service Position ACY-1287A Step 2: In the second blank box, enter your Social Security number.

Arizona Certification For Direct Service Position ACY-1287A Step 3: In the third blank box, enter any aliases, such as your maiden name or nicknames.

Arizona Certification For Direct Service Position ACY-1287A Step 4: In the fourth blank box, enter your date of birth.

Arizona Certification For Direct Service Position ACY-1287A Step 5: In the fifth blank box, enter your street address, city, state and zip code.

Arizona Certification For Direct Service Position ACY-1287A Step 6: Indicate with a check mark whether or not you are currently the subject of a child abuse investigation in Arizona or any other state or jurisdiction.

Arizona Certification For Direct Service Position ACY-1287A Step 7: Indicate with a check mark whether you have ever been the subject of a child abuse investigation in Arizona or any other state or jurisdiction.

Arizona Certification For Direct Service Position ACY-1287A Step 8: If you answered "yes" in response to Step 7, write what the allegations were in the blank space where indicated.

Arizona Certification For Direct Service Position ACY-1287A Step 9: If you answered "yes" in response to Step 7, write when the investigation was conducted in the blank space where indicated.

Arizona Certification For Direct Service Position ACY-1287A Step 10: If you answered "yes" in response to Step 7, write where the investigation was conducted in the blank space where indicated.

Arizona Certification For Direct Service Position ACY-1287A Step 11: If you wish to provide additional information concerning past investigations of child abuse allegations, you may provide a written explanation on the second page. Do not include the names of any children or persons involved in the investigation.

Arizona Certification For Direct Service Position ACY-1287A Step 12: Sign and date the bottom of the first page.