Central Registry Release Of Information Form - Va Department Of Social Services
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1
2VA Department of Social Services
Central Registry Release of Information Form
Adam Walsh Law
Adoptive Parent
Babysitter/Family Day Care
Purpose of Search, Check one:
CASA
Children’s Residential Facility
Custody Evaluation
Day Care Center
Foster Parent
Institutional Employee
Other Employment
School Personnel
Volunteer
Other
MAIL SEARCH RESULTS TO: Agency, Individual or Authorized Agent Requesting Search
Payment/FIPS Code
Name
Catholic Diocese of Arlington
(Use only if assigned by OBI-CRU)
Address
200 N. Glebe Road, Suite 914
State
Zip
A11854
City
Arlington
VA
22203
Contact Name
Dcn. R. Marques Silva
Tel.#
Ext
703-841-3847
Mandatory if agency code
Contact E-Mail
has been assigned
PART I: DETAILS OF INDIVIDUAL WHOSE NAME MUST BE SEARCHED
Full Middle Name – (given at birth) - No initials
Last Name
First Name
(if middle name is an initial, indicate "Initial Only")
Maiden Name (last name before marrage)
Sex
Date of Birth (MM/DD/YYYY)
Race
Male
Female
Driver's License Number or ID #
Social Security Number
Other names used; nicknames, legal names (refer to instruction page)
Current Address (Include Street # and Apt #)
City
State
Zip
Applicant’s Prior Addresses
Include Street # and Apt #
City
State
Zip
Start Date (MM/YY) End Date (MM/YY)
Marital Status
Single
Married
Divorced
Widowed
Partner
If married, list current spouse. If previously married, list all previous spouses. If you have never been married, write ‘N/A’.
First Name
Last Name
Full Middle Name
Date of Birth
Maiden Name
Race
Sex
(MM/DD/YYYY)
(given at birth)
Male
Female
Male
Female
Male
Female
List all of your children.
‘N/A’.
If you have none, write
Include all adult children, step and foster children not living with you.
Last Name
First Name
Full Midle Name
Relationship
Date of Birth
Sex
(MM/DD/YYYY)
(given at birth)
Male
Female
Male
Female
Male
Female
032-02-0151-12-eng (08/15)
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