INSTRUCTIONS: ARIZONA CERTIFICATION STATEMENT FOR PROVIDING CHILD CARE SERVICES (Form CC-201)

Those applying for a position in Arizona to provide child care services are required to submit to a background check concerning their suitability to have unsupervised access to vulnerable persons. Form CC-201 is an affidavit completed by the applicant as part of a background check process that also includes having their fingerprints taken, which will be reviewed by the Arizona Department of Public Safety and the Federal Bureau of investigation. This document can be obtained from the website maintained by the Arizona Department of Economic Security. Make sure you submit the most current version of this form, as previous versions will not be accepted. Failure to submit full and accurate information may be grounds for prosecution.

Arizona Certification Statement For Providing Child Care Services CC-201 Step 1: Enter your first, middle and last name in the first blank box.

Arizona Certification Statement For Providing Child Care Services CC-201 Step 2: Enter your date of birth in the second blank box.

Arizona Certification Statement For Providing Child Care Services CC-201 Step 3: Enter your street address, apartment number (if applicable), city, state and zip code in the third blank box.

Arizona Certification Statement For Providing Child Care Services CC-201 Step 4: Indicate with a check mark whether or not you have been convicted of or are under pending investigation for any prior crimes. If you have, provides the dates, location or jurisdiction, circumstances and outcome.

Arizona Certification Statement For Providing Child Care Services CC-201 Step 5: Answer the next four questions by checking "yes' or "no" as appropriate.

Arizona Certification Statement For Providing Child Care Services CC-201 Step 6: The second page concerns non-appealable offenses. Check "yes" or "no" in response to all non-appealable offences listed.

Arizona Certification Statement For Providing Child Care Services CC-201 Step 7: The third page concerns offenses appealable five years after conviction. Check "yes" or "no" in response to all such offences listed.

Arizona Certification Statement For Providing Child Care Services CC-201 Step 8: The fourth and fifth pages concerns appealable offenses. Check "yes" or "no" in response to all such offenses listed.

Arizona Certification Statement For Providing Child Care Services CC-201 Step 9: Sign and date the first page in the presence of a notary public.