APPLICATION FOR CERTIFIED WELFARE FRAUD INVESTIGATOR

E-mail: _______________________________________________________________________

Have you been convicted of a felony or crime of moral turpitude? 

Yes________  No _______

(If yes, provide details on separate sheet.)

Education

College: ______________________________________________________________________

College Address: _______________________________________________________________

Degree: ________________________________________  Date: _________________________

Applicant's Certification Agreement

I, the undersigned, certify that the information provided in this application is true and correct.  I agree to abide by the UCOWF Code of Ethics and perform all professional duties in accordance with applicable government standards.  I authorize the Certification Board to verify the information I have submitted.  I agree to cooperate fully with the UCOWF Ethics Committee should an allegation of unethical conduct or a violation of professional work standards be lodged against me in the future.

Applicant's Signature ______________________________________  Date ________________

Third Party Verification of Application

This section must be signed by someone in authority, other than the applicant, who has documents on file to support the information provided about the applicant's education and work experience.

I, the undersigned, have reviewed the information provided by this applicant and certify that the information is correct and supported by documents on file with my organization.

Name: ___________________________________________________________________

Title: ____________________________________________________________________

Agency: __________________________________________________________________

Telephone: (_________)______________________________________________________

Signature _______________________________________ Date ______________________

Work Experience

Complete this section for each employer you want to use to meet the requirements for certification.  YOU MUST RESPOND TO ALL OF THE QUESITONS.  You may make additional copies of this form.

Agency: _____________________________________________________________________

Agency  Mailing Address: _______________________________________________________

_____________________________________________________________________________

Supervisor: ________________________________________Telephone: (_____)____________

Date of Employment:     From______________________ To ____________________________

Beginning with your most recent position, list the job duties you have held with this organization and length of service in each position:

Job Title: ______________________________________ From___________ To_____________

Job Title: ______________________________________ From___________ To_____________

Job Title: ______________________________________ From___________ To_____________

Job Title: ______________________________________ From___________ To_____________

Full Time Investigator?  Yes ______ No______  If you answered no to this question, please attach an additional sheet to this application describing what other duties you perform.

QUALIFYING EXPERIENCE

There are three types of investigations that you may use to qualify you for certification:

ADH INV  -          Welfare fraud investigations that were referred to an administrative

                  disqualification hearing without further investigation by another person.

PROS INV  -        Welfare fraud investigations that were referred to a prosecuting attorney

                               without further investigation by another person.

FPI INV  -             Welfare fraud prevention investigations that were referred to you by a

                               certification worker and were conducted before the person being investigated

                               was certified for benefits.  You must have been assigned to a unit or group

                               separate from the eligibility worker.

Have you personally conducted investigations as described under Qualifying Experience?

ADH INV:   Yes____ No____     Dates:  From______________ To ______________      

PROS INV: Yes____ No ____     Dates:  From______________ To ______________

FPI INV:     Yes ____ No ____     Dates:  From______________ To ______________

What percentage of your time did you spend conducting these investigations?

ADH INV:  _____________      PROS INV:  ______________      FPI INV:  _____________

Approximately how many of these have you conducted?

ADH INV:  _____________      PROS INV:  ______________      FPI INV:  _____________

Do you supervise investigators who conduct investigations as described under Qualifying Experience?

ADH INV: Yes____ No____   PROS INV: Yes____ No ____  FPI INV: Yes ____ No ____

How many investigators do you supervise that conduct these investigations? 

ADH INV:  __________          PROS INV:  __________           FPI INV:  __________

How many investigations do they conduct annually?

ADH INV:  __________          PROS INV:  __________           FPI INV:  __________

What dates did you supervise these investigators?

ADH INV:   Dates:  From______________ To ______________      

PROS INV: Dates:  From______________ To ______________

FPI INV:     Dates:  From______________ To ______________

Please attach any additional information or clarification that you would like the Board to consider in determining your eligibility for certification.

PLEASE MAIL YOUR COMPLETED APPLICATION AND TESTING FEE TO: