Authorization For Background Check printable pdf download

Authorization For Background Check

CFS 689

6/2001

State of Illinois

Department of Children and Family Services

AUTHORIZATION FOR BACKGROUND CHECK

Child Abuse and Neglect Tracking System (CANTS)

For Programs NOT Licensed by DCFS

NOTE: Do not use this form if you are an applicant for licensure or an employee/volunteer of a licensed child

care facility. Please contact your licensing representative.

Name:

Last

First

Middle

Date of Birth:

Gender (circle): Male

Female

Race:

Current Address:

Street/Apt #

City

State

Zip Code

List all addresses at which you have resided in the past five years:

List maiden name and/or all other names by which you have been known: (last, first, middle)

I hereby authorize the Illinois Department of Children and Family Services to conduct a search of the Child Abuse and Neglect

Tracking system (CANTS) to determine whether I have been a perpetrator of an indicated incident of child abuse and/or neglect

or involved in a pending investigation. I further consent to the release of this information to the agency listed below.

Mail this request to:

Department of Children and Family Services

406 E. Monroe – Station # 30

Signed

Date

Springfield, IL 62701

Please type, use bold letters or label:

(Agency Name)

(Contact Person)

(Address)

(City/State/Zip)

Authorization For Background Check