An application for a training voucher shall be accepted only for a pre-service training, a statewide conference, or a national conference. Applicant must hold a current Maryland Child Care Credential of Level Two or higher. INSTRUCTIONS: Complete all information in the spaces provided. All applications must be accompanied by required documentation. Incomplete applications will not be processed. Application for Voucher must be submitted not less than 60 days before the date of training. Personal Information Applicant's First Name * Applicant's Middle Name Applicant's Last Name * Applicant's Maiden Name Last four digit of Social Security Number * Annual Family Income * Federal Tax Form 1040 - Line 22 CCATS/Party ID# * Mailing Address * Country * United States Address 1 * Address 2 City * State * - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--Armed Forces (Americas)Armed Forces (Europe, Canada, Middle East, Africa)Armed Forces (Pacific)American SamoaFederated States of MicronesiaGuamMarshall IslandsNorthern Mariana IslandsPalauPuerto RicoVirgin Islands ZIP code * Daytime Phone * Alternate Phone Email Address * I am a * Check the appropriate box. I am a Family Child Care Provider I work in a Child Care Center Registration Center Name License TRAINING INFORMATION Check the appropriate box. CONFERENCE PRE-SERVICE COURSE Title * Date * Trainer / Training Organization Name * Street Address * Country * United States Address 1 * Address 2 City * State * - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--Armed Forces (Americas)Armed Forces (Europe, Canada, Middle East, Africa)Armed Forces (Pacific)American SamoaFederated States of MicronesiaGuamMarshall IslandsNorthern Mariana IslandsPalauPuerto RicoVirgin Islands ZIP code * COST * Attachment * Conference/Pre-Service Training advertisement (Information must include date of conference/Pre-Service training, cost, session title, organization name and if applicable, OCC assigned approval number.) Files must be less than 2 MB.Allowed file types: txt rtf html pdf doc docx odt ppt pptx odp xls xlsx ods xml. Upload All information on this application is true and accurate to the best of my knowledge. I understand that any false statement on this application will result in it being rejected. I further understand that if I receive a training vocher I will: Attend the Conference/Pre-Service training named on the voucher; Submit documentation to the Office of successful completion of the training; Be required to repay the amount of the voucher if I do not successfully complete the training for which it was issued; and No longer be eligible for training vouchers if I do not successfully complete the training for which it was issued. Applicant's Signature Clear signature Date * Submit
