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CCA-1212A FORNA (4-16) Staff Name: Date of Birth: DIRECT SERVICE POSITION SUPPLEMENT #1 [Additional Address(es)] The Direct Service Position Supplement #1 is to be completed by individuals who have completed the Direct Service Position form and have indicated that they have resided in other state(s) in the past five years. The information provided will be used by the Employer to complete and submit the Request for Search for Background Checks form. This information is confidential and will be retained by the Employer as such with the exception that the Employer is required to attach it to the background check request identified above. I certify that I have resided in other state(s) in the past five (5) years and that the required information is indicated below. It contains complete address(es) which include number, street, city, state, zip code and dates during which I resided there. Please print or type. Date Address Page 37 CCA-1212A (4-16) – Arizona Department of Economic Security